AH II Resp AQ + Chest Trauma (Exam 1)

The nurse is assessing a patient with possible pulmonary embolism (PE). For which symptom would the nurse assess? Select all that apply. One, some, or all responses may be correct. A. Productive cough B. Bloody sputum C. Inspiratory chest pain D. Dizziness and fainting E. Shortness of breath (SOB) worsening over the last 2 weeks

A, B, C, D Rationale PE may cause a dry or productive cough with bloody sputum (hemoptysis). Syncope, hypotension, and fainting are symptoms associated with PE. Sharp, pleuritic, inspiratory chest pain is also characteristic of PE. Sudden, not gradual, SOB occurs with PE.

Which precautionary measure would the nurse plan to take while a patient is on heparin sodium therapy? Select all that apply. One, some, or all responses may be correct. A. Monitor the platelet count. B. Have the antidote, vitamin K, readily available. C. Monitor the partial thromboplastin time (PTT). D. Monitor the international normalized ratio (INR). E. Have the antidote, protamine sulfate, readily available.

A, C, E Rationale Monitoring the platelet count daily helps detect any heparin-induced thrombocytopenia because a decrease in platelet count is a common adverse effect caused by the use of heparin sodium. Regular monitoring of PTT is necessary because it helps detect side effects and prevent complications. Protamine sulfate is used as an antidote in emergency situations caused by heparin overdose because it reverses the anticoagulation effect by binding to heparin. While using warfarin, patients may experience adverse effects of the drug; vitamin K is used as an antidote because of its coagulating effect. Regular monitoring of INR is recommended when a patient is on warfarin therapy.

The patient who has a venous thromboembolism in the upper arm is to begin receiving prescribed oral warfarin. The nurse is aware that the patient is currently receiving an IV heparin infusion. Which action would the nurse take? Administer both of the medications as prescribed. Decrease the heparin infusion rate by 50%. Clarify the warfarin and heparin prescriptions with the health care provider. Hold the dose of warfarin until the heparin prescription is discontinued.

Administer both as prescribed Rationale Although both heparin and warfarin are anticoagulants, they have different mechanisms and onsets of action. Because warfarin has a slow onset, it must be started while the patient is still receiving heparin to maintain a safe level of anticoagulation for effective treatment of the venous thromboembolism. It is not necessary to clarify the prescription as the patient must take warfarin while on the heparin because warfarin has a slow onset. Warfarin should not be held as it can be given while the heparin is being administered. The heparin dosing is based on serial measures of the partial thromboplastin time (PTT); the nurse should not change the rate of heparin infusion based on the warfarin being prescribed.

A patient with chronic obstructive pulmonary disease (COPD) suddenly becomes dyspneic with a respiratory rate of 32 breaths/min and an oxygen saturation of 94%. The patient appears pale and anxious and is using accessory muscles to breathe. Which action would the nurse take? A. Notify the Rapid Response Team. B. Request an order for a chest x-ray. C. Obtain an order for arterial blood gases. D. Apply high-flow oxygen with a Venturi mask.

Obtain an order for ABG Rationale The patient has developed respiratory distress. Even though the oxygen saturation level is within normal limits, a more accurate assessment of hypoxemia is with arterial blood gases. Giving high-flow oxygen with a Venturi mask may increase anxiety and cause oxygen-induced hypercapnia in patients with COPD. Unless the patient exhibits signs of respiratory failure with hypoxemia or cyanosis, notifying the Rapid Response Team is not necessary. A chest x-ray may be indicated after the patient is stabilized to help determine the cause of the respiratory distress.

A patient receiving mechanical ventilation has had the positive end-expiratory pressure (PEEP) decreased from 10 cm H 2O to 5 cm H 2O. Which change in the patient's status would prompt the nurse to notify the health care provider? Breath sounds are distant over both lung bases. The patient is requiring more frequent suctioning. Oxygen saturation decreases from 95% to 80%. The patient is coughing up more sputum.

Oxygen saturation decreases from 95% to 80% Rationale PEEP is used to improve oxygenation and reduce atelectasis. A drop in oxygen saturation when PEEP is reduced should be reported to the health care provider because oxygenation may not be effective. The decrease in breath sounds may be related to the reduction in PEEP, but it is less urgent than the change in oxygenation. Increased secretions and coughing are not abnormal when PEEP is reduced during mechanical ventilation.

A patient with acute respiratory distress syndrome (ARDS) is being mechanically ventilated. The health care provider has prescribed10 cm H 2O of positive end-expiratory pressure (PEEP). Which data would inform the nurse that the PEEP was effective? Urine output increases to 45 mL/hr. Heart rate increases from 96 beats/min to 110 beats/min. c Blood pressure decreases from 120/80 mm Hg to 92/65 mm Hg.

Oxygen saturation increases from 85% to 92%. Rationale The patient with ARDS often requires intubation and mechanical ventilation with PEEP. PEEP improves oxygenation by enhancing gas exchange and preventing atelectasis. An improvement in oxygen saturation would be used to evaluate the effectiveness of adding PEEP to the patient's mechanical ventilation mode. Improving the patient's oxygenation status would help to stabilize the vital signs, not cause tachycardia or hypotension. Adjusting the patient's PEEP would not alter the urine output.

The nurse assists with the intubation of an 176-lb (80-kg) patient who will receive mechanical ventilation on assist/control mode with positive end-expiratory pressure (PEEP). Which ventilator setting would the nurse expect to be maintained over the next shift? Fraction of inspired oxygen (Fio 2) as high as possible Tidal volume of 400 mL Oxygen flow rate of 20 L/min PEEP between 5 and 15 cm H 2O

PEEP between 5 and 15 cm H 2O Rationale Patients receiving PEEP ventilation should have pressure settings between 5 and 15 cm H 2O. Because prolonged use of high Fio2 can damage lungs, the Fio 2 should be lowered to the lowest possible amount. The oxygen flow rate should be 40 L/min. The patient's tidal volume should be 6 to 8 mL/kg; for this patient, the range would be 480 to 640 mL.

Which patient needs immediate attention by the nurse? 57-year-old who was recently extubated and is reporting a sore throat 54-year-old who is mechanically ventilated and has tracheal deviation 60-year-old who is receiving oxygen (O 2) by facemask and whose respiratory rate is 24 breaths/min 40-year-old who is receiving continuous positive airway pressure (CPAP) and has intermittent wheezing

Rationale The 54-year-old patient is showing signs of a tension pneumothorax that could lead to decreased cardiac output and shock if not addressed promptly. The 40-year-old patient has intermittent adventitious breath sounds but is not in immediate danger. The 57-year-old patient has mild discomfort but is not in danger of a life-threatening situation. The 60-year-old patient has mild tachypnea but is not in immediate distress or danger.

A patient is being mechanically ventilated via synchronized intermittent mandatory ventilation with a set rate of 10 breaths/min. The patient is sedated and not breathing spontaneously. The most recent arterial blood gas (ABG) results are: pH = 7.32; partial pressure of arterial oxygen (PaO 2) = 85 mm Hg; and partial pressure of arterial carbon dioxide (PaCO 2) = 55 mm Hg. What is the nurse's interpretation of these results? Ventilation is adequate to maintain oxygenation. Ventilation is excessive; respiratory alkalosis is present. Ventilation is inadequate; respiratory acidosis is present. Ventilation status cannot be determined from the information presented.

Ventilation is inadequate; respiratory acidosis is present. Rationale The PaCO 2 indicates the patient is not effectively ventilating and more frequent or larger breaths are necessary. The settings of the ventilator are causing hypoventilation and respiratory acidosis. If the ventilation was adequate, the PaCO 2 would be within normal limits. If the ventilation was excessive, the PaCO 2 would be below normal. The PaCO 2 is sufficient information to determine ventilation.

A family member of a patient who has acute respiratory distress syndrome (ARDS) asks the nurse how long it will take for the patient to get better. The nurse reviews the medical record and notes that the patient has been receiving mechanical ventilation for 3 weeks. Which information would the nurse provide to the family member? "Multisystem organ changes occur at 2 weeks." "After 2 weeks, some lung changes may be irreversible." "Patients who are ventilator dependent usually die." "Recovery may be complete, but it will take months."

"After 2 weeks, some lung changes may be irreversible." Rationale Pulmonary fibrosis with progression occurs after 10 days of onset of ARDS. Patients who survive to this point will have permanent lung changes and may remain ventilator dependent indefinitely. Although many patients die, telling the family member this initially will destroy any hope for a good outcome; this must be discussed with the health care provider, the nurse, and possibly the palliative care team. Multisystem organ changes are more likely but have not necessarily occurred. Recovery is rarely complete at this stage.

Which term is used to refer to alveolar damage from an inflammatory response?

-Bilevel positive airway pressure (BiPAP)

Which drug increases cardiac output by improving myocardial contractility?

-Milrinone -positive inotropic drug that increases the contractility of the cardiac musculature, increasing CO

biotrauma

-alveolar damage from an inflammatory response -lung problem that occurs when a patient is on mechanical ventilation

Symptoms of tension pneumothorax

-asymmetry -tracheal deviation toward the unaffected side -dyspnea -absent breath sounds -jugular venous distention (JVD) -cyanosis -hyperresonance to percussion over the affected area

Which expiratory volume value signifies a poor prognosis in patients with deep chest trauma? 10 mL/kg 15 mL/kg 20 mL/kg 25 mL/kg

10 mL/kg Rationale An expiratory volume of less than 15 mL/kg is considered to be a sign of poor prognosis. The chances of survival are very bleak. An expiratory volume of 15 mL/kg, 20 mL/kg, and 25 mL/kg indicate fair prognosis in patients with chest trauma.

Which drug is an antidote for heparin?

Protamine sulfate

atelectrauma

shear injury to alveoli while opening and closing

barotrauma

when damage to lungs is caused by excessive pressure

A patient with pneumonitis caused by inhaling an irritant is receiving 100% oxygen for treatment of worsening hypoxemia. The patient has increasing dyspnea and work of breathing. A chest x-ray reveals a ground-glass appearance in both lungs. Which condition would the nurse suspect this patient has developed? Aspiration pneumonia Oil or fat embolism Tension pneumothorax Acute respiratory distress syndrome (ARDS)

ARDS Rationale Patients who have these symptoms most likely have ARDS. The ground-glass appearance on the x-ray confirms this diagnosis. Patients with pulmonary embolism may have normal chest x-rays or may have infiltrates localized to the area around the embolism. Patients with pneumonia typically have infiltration or consolidation of one or more lobes. A tension pneumothorax is visible on x-ray with one-sided lung involvement.

Which drug is an antidote to fibrinolytic therapy?

Aminocaproic acid -to prevent excess bleeding

The nurse is extubating a patient who has been receiving mechanical ventilation for several days. Which action would the nurse plan to take directly after removal of the endotracheal (ET) tube? A. Monitoring vital signs B. Suctioning the oropharynx C. Asking the patient to cough D. Hyperoxygenating the patient

Asking the patient to cough Rationale: The patient should be asked to cough immediately after removal of the ET tube to help clear secretions. The nurse should hyperoxygenate the patient and suction the oropharynx prior to removal of the ET tube. After the ET tube is safely removed, the nurse should monitor vital signs every 5 minutes initially.

A patient in the ICU on mechanical ventilation appears increasingly restless and picks at the bedcovers. Which action would the nurse take? A. Increase the sedation. B. Assess for adequate oxygenation. C. Request that the family members leave. D. Explain the breathing tube to the patient.

Assess for adequate oxygenation Increase the sedation. Assess for adequate oxygenation. Request that the family members leave. Explain the breathing tube to the patient.

Which risk factor increases a patient's risk for a venous thromboembolism that may progress to a pulmonary embolism? Select all that apply. One, some, or all responses may be correct. A. Nonsmoker B. 72 years of age C. Presence of a central venous catheter D. Admission weight of 290 lb (131.8 kg) E. Ability to ambulate with assistance of one person

B, C, D Rationale Several factors place a patient at an increased risk for developing a pulmonary embolism from a thromboembolism. Risk factors that should be assessed include prolonged immobility, central venous catheter, surgery, obesity, advanced age, history of thromboembolism, smoking history, pregnancy, estrogen therapy, heart failure, stroke, and cancer.

which mode of ventilation would the nurse expect to be prescribed for a patient who has sleep apnea?

Bilevel positive airway ventilation (BiPAP)

Which change would the nurse anticipate in a patient with worsening acute respiratory distress syndrome (ARDS)? Select all that apply. One, some, or all responses may be correct. A. Increase in lung volume B. Expansion of lung channels C. Reduction in surfactant activity D. Damage to type II pneumocytes E. Edema around terminal airways

C, D, E Rationale ARDS occurs as a result of an acute lung injury. The injury typically happens in the alveolar-capillary membrane. As a result of the injury, surfactant is diluted by extra fluid in the lungs. Type II pneumocytes are damaged, and edema forms around terminal airways. Surfactant activity is reduced because of the damage of type II pneumocytes. The collapsed alveoli cannot exchange gases, and edema forms around terminal airways. In ARDS, lung volume is decreased, and lung channels are compressed.

A patient has deep vein thrombosis. The nurse is teaching the patient's caregiver about measures for preventing pulmonary embolism. Which statement made by the caregiver indicates effective learning? Select all that apply. One, some, or all responses may be correct. A. "Help the patient to cross the legs." B. "Gently massage the patient's leg muscles." C. "Change the patient's position every 2 hours." D. "Avoid placing a pillow under the patient's knee." E. "Elevate the affected limb above the heart level."

C, D, E Rationale Changing the patient's position every 2 hours may reduce the pressure in specific areas and promote blood circulation. Placing a pillow under the knees can cause pressure under the popliteal space. Elevation of the affected limb 20 degrees or more above the level of the heart improves the venous return. Crossing legs should be avoided to prevent pressure on the blood vessels in the affected limbs, which may result in clot formation. The caregiver should refrain from massaging the leg muscles to prevent dislodging of the clot and causing pulmonary embolism.

Which component of a patient's plan of care is based on the ventilator bundle approach to prevent ventilator-associated pneumonia (VAP)? Select all that apply. One, some, or all responses may be correct. A. Placing a nasogastric tube B. Administering antibiotic prophylaxis C. Removing subglottic secretions continuously D. Placing the patient in a negative airflow room E. Handwashing before and after contact with the patient F. Elevating the head of the bed at least 30 degrees when possible

C, E, F Rationale Continuous removal of subglottic secretions, elevating the head of the bed at least 30 degrees whenever possible, and handwashing before and after contact with a patient are all part of a VAP bundle. Antibiotics are not given prophylactically; they are given on the basis of cultures to prevent an increase in drug-resistant organisms. A nasogastric tube is not part of the VAP bundle. If a patient is going to be mechanically ventilated for a prolonged period of time, postpyloric or gastrostomy tubes are preferred over nasogastric tubes for nutrition. Placing a patient in a negative airflow room is not part of the VAP bundle but would be used if a patient had an airborne communicable disease.

Which finding is characteristic of hypoxic respiratory failure? Select all that apply. One, some, or all responses may be correct. A. Confusion B. Diarrhea C. Irritability D. Restlessness E. Tachycardia

Confusion, Irritability, Restlessness When a patient's oxygen level is low, the patient may be restless, irritable, or confused because decreased oxygen levels affect cerebral blood flow. The heart rate usually increases to compensate for low perfusion in hypoxemia. Diarrhea is not a manifestation of hypoxemia.

Which finding is consistent with a pulmonary embolism (PE)? Select all that apply. One, some, or all responses may be correct. A. Crackles B. Diaphoresis C. Bradycardia D. Low-grade fever E. Severe headache

Crackles, Diaphoresis, Low-grade fever A PE is a collection of particulate matter that enters venous circulation and lodges in the pulmonary vessels. Crackles, diaphoresis, and low-grade fever are some of the signs of PE. Crackles are heard because the embolism blocks pulmonary vessels and fluid accumulates. Diaphoresis occurs because of the pooling of fluid. Tachycardia occurs during a PE; the patient experiences an elevated heart rate as the heart works harder to circulate blood throughout the body. A severe headache is not a sign of PE.

A patient who has been on a ventilator for the past week has become increasingly hypoxemic despite increased oxygen settings. Which phase of acute respiratory distress syndrome (ARDS) would the nurse suspect the patient is experiencing? A. Increased compliance B. Exudative C. Resolution D. Fibrosing alveolitis

Fibrosing alveolitis In the fibrosing alveolitis phase, increasing lung involvement reduces gas exchange and oxygenation. ARDS decreases rather than increases lung compliance. In the exudative phase patients experience dyspnea and tachypnea and require oxygen via mask or nasal cannula. The resolution phase usually occurs after 14 days. Resolution of the injury can occur; if not, the patient either dies or has chronic disease.

A patient is receiving mechanical ventilation with a fraction of inspired oxygen (Fio 2) of 85%. The health care provider has prescribed the positive end-expiratory pressure (PEEP) to be increased from 10 cm of H 2O to 15 cm of H 2O. If the increase in PEEP is successful, which change will the nurse anticipate being made to the ventilator settings? Increase the tidal volume. Decrease the tidal volume. Increase the oxygen flow rate. Decrease the oxygen flow rate.

Decrease the oxygen flow rate Rationale PEEP is added when patients cannot maintain adequate gas exchange even with high-flow oxygen. The effect of preventing atelectasis should increase arterial blood oxygenation and allow the oxygen flow rate to be decreased. Adding PEEP does not have a direct effect on tidal volume, which is determined by the patient's weight and lung capacity.

A patient requiring mechanical ventilation for treatment of pneumonia becomes agitated, restless, and shows symptoms of respiratory distress. The mechanical ventilator high-pressure alarm has been activated. Which action would the nurse take? A. Medicate the patient with a sedating agent. B. Increase oxygen delivery to 100% through the ventilator. C. Check the mechanical ventilator data for possible causes of the alarm. D. Disconnect the ventilator, and provide ventilation with a self-inflating bag.

Disconnect ventilator, and provide ventilation with a self inflating bag Rationale When a patient shows signs of respiratory distress while being mechanically ventilated, the nurse should focus on the patient, not the mechanical ventilator. The first best action is to disconnect the ventilator and use a self-inflating bag to ventilate the patient while problem solving the cause of the alarm. Although it may be necessary to administer sedation to the patient, the nurse must attempt to stabilize the patient first. The nurse should not increase oxygen through the ventilator until the cause of the alarm is determined.

A patient recovering from a pulmonary embolism is receiving low-molecular-weight heparin and warfarin. The patient's international normalized ratio (INR) was 2.1 yesterday and is 2.4 today. After reporting today's laboratory value to the health care provider, the nurse would anticipate which prescription? A. Discontinue the heparin, and continue the warfarin. B. Discontinue the warfarin, and administer phytonadione. C. Discontinue the heparin, and administer protamine sulfate. D. Continue the heparin and warfarin, and repeat the INR in 1 day.

Discontinue heparin, and continue the warfarin Rationale The patient will typically take both drugs until the INR is more than 2.0 for 24 hours and then will stop taking the heparin. Patients may take warfarin for 3 to 6 weeks or indefinitely. There is no need to administer protamine sulfate or phytonadione, which are antidotes for heparin and warfarin, because the INR is within desired limits to prevent clotting.

A patient being treated for a pulmonary embolism is receiving heparin, oxygen, and IV fluids. The nurse notes a persistent blood pressure of 88/58 mm Hg and a urine output of 20 mL/hr. Which medication would the nurse anticipate will be prescribed? Vitamin K Dobutamine Protamine sulfate Aminocaproic acid

Dobutamine Rationale Patients who have persistent hypotension with a pulmonary embolism may be given an inotropic agent such as dobutamine to improve cardiac output. Vitamin K is the antidote for warfarin, protamine sulfate is the antidote for heparin, and aminocaproic acid is the antidote for fibrinolytic therapy.

Which term describes bleeding into the chest cavity? Stridor Hemothorax Thoracotomy Pneumothorax

Hemothorax Rationale Hemothorax is bleeding into the chest cavity. Stridor is a high-pitched, crowing noise during inspiration caused by laryngospasm or edema around the glottis. Thoracotomy is a surgical incision into the chest wall. Pneumothorax is air in the pleural space causing a loss of negative pressure in chest cavity, a rise in chest pressure, and a reduction in vital capacity, which can lead to lung collapse.

A patient with acute respiratory distress syndrome (ARDS) is receiving mechanical ventilation. Which outcome would be supported by the plan to turn the patient every 2 hours? A. Reduce lung fibrosis B. Increase gas exchange C. Enhance blood clotting D. Improve lung compliance

Increase gas exchange Rationale Positioning may be important in promoting gas exchange in patients with ARDS, but the exact position is controversial. Manually turning the patient every 2 hours has been shown to improve perfusion. Turning the patient does not affect lung compliance or reduce lung fibrosis. Turning helps prevent thrombophlebitis, or clots, from developing.

A patient sitting upright and receiving high-flow oxygen with a nonrebreather mask appears anxious and has a respiratory rate of 30 breaths/min, a heart rate of 110 beats/min, and an oxygen saturation of 88%. The patient is using accessory muscles to breathe and appears fatigued. For which procedure would the nurse prepare to assist? A. Insertion of an oral or nasal airway B. Chest x-ray and arterial blood gases C. Intubation and mechanical ventilation D. Thoracostomy and chest tube insertion

Intubation and mechanical ventilation Rationale The patient is hypoxic despite receiving oxygen and is showing signs of increasing distress and fatigue; intubation and mechanical ventilation are necessary to treat respiratory failure in this patient. A chest x-ray and arterial blood gases may be performed after the patient is stabilized as part of the ongoing assessment. An oral airway is used when the patient cannot maintain a patent airway. A thoracostomy and chest tube insertion would be performed for signs of a pneumothorax.

A patient is refusing to wear pneumatic compression stockings while in bed, stating he does not like how they feel and they keep him awake. Which response would the nurse provide? A. "Let me talk to the health care provider about discontinuing them." B. "Would you like me to give you medication to help you sleep?" C. "It is important to wear them in bed so you don't develop a blood clot in your legs." D. "I'll give you a break from them for an hour, but then I'll need to put them back on."

It's important to wear them in bed so you don't develop a blood clot in your legs Rationale The continuous use of antiembolism and pneumatic compression stockings is an essential intervention in the prevention of venous thromboembolism. Providing education to patients may help with their refusal to wear compression stockings. It may be necessary to request a prescription for a sleep aid, but this is not the best response.

Which procedure is associated with a patient developing ICU psychosis?

Mechanical ventilation

Which Fowler position is recommended for a patient with a pulmonary contusion? Low Fowler High Fowler Standard Fowler Moderate Fowler

Moderate Fowler Rationale The patient with a pulmonary contusion is placed in a moderate-Fowler position to maintain ventilation and oxygenation. Low-, high-, and standard-Fowler positions do not ensure proper respiration and are not suitable.

A postoperative patient exhibits a sudden onset of shortness of breath accompanied by syncope when getting up to a chair. The nurse assists the patient into the bed and performs an assessment that reveals a heart rate of 110 beats/min and a blood pressure of 88/56 mm Hg. The patient appears cyanotic and has distended neck veins. Which action would the nurse take first?

Notify the Rapid Response Team Rationale A patient at risk for pulmonary embolism (PE) with the symptom cluster described should be assumed to have a PE, and the Rapid Response Team should be called. Once this is done, the nurse should continue assessing the patient and administer oxygen.

Which factor increases a patient's risk for a venous thromboembolism (VTE)? Select all that apply. One, some, or all responses may be correct. A. Obesity B. Malnutrition C. Advancing age D. Vitamin deficiency E. Prolonged immobility

Obesity, Advancing age, Prolonged immobility Rationale In VTE, blood tends to clot in the veins. Obesity contributes to the deposition of cholesterol in the veins, leading to clot formation. The elasticity of veins decreases with age, which leads to clot formation. Prolonged immobility increases the risk for VTE because of venous pooling. Malnutrition and vitamin deficiency are not risk factors for VTE; they are not associated with functions related to blood vessels and blood clotting mechanisms.

A patient has developed a pulmonary embolism. Which laboratory test would the nurse anticipate being prescribed before beginning heparin therapy?

Partial thromboplastin time (PTT) A baseline PTT should be obtained before the administration of heparin

Which critically ill patient is at high risk for developing acute respiratory distress syndrome (ARDS)? A. Patient with atrial fibrillation B. Patient with acute kidney failure C. Patient with aspiration pneumonia D, Patient with diabetic ketoacidosis (DKA)

Patient with aspiration pneumonia Aspiration of acidic gastric contents is a risk for ARDS. Patients with DKA may develop metabolic acidosis, but not ARDS, which develops in lung injury. Atrial fibrillation does not cause lung injury unless embolization occurs. Acute kidney failure results in metabolic acidosis, not in acute lung injury.

Which comfort measure would the nurse plan to use for a patient who has orthopnea? A. Place in upright position B. Encourage frequent ambulation C. Suggest an order for bronchodilator D. Provide low-flow oxygen by nasal cannula

Place the patient in an upright position to facilitate breathing Patients who have orthopnea have increased dyspnea when lying down and should be placed in an upright position to facilitate breathing. Dyspnea that occurs with exercise may be managed by a gradual increase in activity. The patient with orthopnea is not necessarily hypoxic and does not need oxygen unless oxygen saturation or blood gas measures indicate hypoxia. Patients who have wheezing may need bronchodilator therapy.

A patient formerly on synchronous intermittent mandatory ventilation is placed on a T-piece to begin weaning from mechanical ventilation. Seven minutes later, the patient's oxygen saturation decreases from 90% to 70%, and the patient becomes tachycardic, diaphoretic, and anxious. Which action would the nurse take? A. Call the Rapid Response Team. B. Instruct the patient to breathe deeply and try to relax. C. Give sedation medication to help the patient continue the weaning. D. Place the patient back on the recent mechanical ventilator settings.

Place the pt back on the recent mechanical ventilator setting Rationale The patient is showing signs of distress with the weaning process; the nurse should place the patient back on the ventilator or facilitate the process for having mechanical ventilator support reinitiated. The anxiety is a response to hypoxemia; a patient who has reached this level of distress is unlikely to be able to breathe more deeply or relax in response to instructions. A Rapid Response Team call is not indicated because weaning is a controlled process and the health care team works closely together to monitor the patient's tolerance of weaning and reinitiating mechanical ventilation. Giving sedation agents will decrease the patient's drive to breathe.

A patient who has been admitted for a pulmonary embolism is receiving a heparin infusion. Which laboratory result would the nurse monitor to detect a possible complication of heparin therapy?

Platelet count

A patient has been receiving heparin subcutaneously for 4 days. For which laboratory value would the nurse contact the health care provider? A. Hemoglobin of 14.2 g/dL B. Platelet count of 50,000/mm 3 C. International normalized ratio (INR) of 1.1 D. Activated partial thromboplastin time of 35 seconds

Platelet count of 50,000/mm3 Rationale The normal range for platelets is 200,000/mm 3 to 400,000/mm 3. Platelets are needed for blood clotting. This patient's platelet count is extremely low, and he or she is at risk for bleeding. The low platelet count may be an indication of an adverse reaction to heparin known as heparin-induced thrombocytopenia (HIT). The heparin must be discontinued, and the patient may need to receive platelet therapy before life-threatening hemorrhage occurs. The hemoglobin, INR, and activated partial thromboplastin time values are is normal.

Which term describes air in the pleural space? Stridor Hemothorax Thoracotomy Pneumothorax

Pneumothorax Rationale Pneumothorax is air in the pleural space causing a loss of negative pressure in chest cavity, a rise in chest pressure, and a reduction in vital capacity, which can lead to a lung collapse. Stridor is a high-pitched, crowing noise during inspiration caused by laryngospasm or edema around the glottis. Hemothorax is bleeding into the chest cavity. Thoracotomy is a surgical incision into the chest wall.

A patient who has recently been extubated is hoarse and has a cough. Which action would the nurse take? Suction the patient to remove secretions and encourage deep breathing. Notify the Rapid Response Team that the patient may need to be reintubated. Notify the health care provider, and request a prescription to administer racemic epinephrine. Position the patient in a semi-Fowler position, and continue to monitor.

Position the patient in a semi-Fowler position, and continue to monitor. Rationale Coughing and difficulty clearing secretions are early signs of possible obstruction; the nurse should monitor the patient closely and position the patient in a semi-Fowler position. Stridor is a late sign and signifies an emergency requiring racemic epinephrine and possible reintubation. Suctioning the patient may increase irritation and cause increased swelling of the airway.

Several hours after extubation, the patient reports a sore throat and cough, and the nurse notes a hoarse voice. Which action would the nurse take? A. Notify the Rapid Response Team. B. Prepare for reintubation at the bedside. C. Encourage use of an incentive spirometer. D. Request a prescription for nebulized racemic epinephrine.

Prepare for reintubation at the bedside Rationale The patient is experiencing signs of throat irritation, which are common after extubation. Incentive spirometry is used to prevent atelectasis and pneumonia. The Rapid Response Team should be notified if the patient experiences stridor or other signs of airway obstruction. Racemic epinephrine is used to treat stridor. Reintubation would be used if the patient could not maintain ventilation.

Which action for the care of a patient who has just been extubated would the nurse delegate to assistive personnel (AP)? Adjust the nasal oxygen flow rate. Take vital signs every 5 minutes. Assess the patient's ability to swallow liquids. Teach about incentive spirometer use.

Take vital signs every 5 minutes

Which adverse effect is associated with the use of positive end-expiratory pressure (PEEP)? A. Lung infection B. Ventilatory failure C. Pulmonary embolism D. Tension pneumothorax

Tension pneumothorax PEEP is used to prevent the alveoli from collapsing at the end of expiration. The most serious side effect of PEEP is tension pneumothorax, in which the alveoli rupture and air accumulates in the pleura. Infection is not associated with application of PEEP. PEEP is used for prevention of ventilatory failure. PEEP does not affect the clotting mechanism of the body; pulmonary embolism is not associated with PEEP.

A patient who is on mechanical ventilation is setting off the high-pressure alarm. For which situation would the nurse insert an oral airway? A. The patient has a decreased airway size. B. The patient has increased oral mucus secretions. C. The patient experiences decreased compliance of the lungs. D. The patient is biting on the endotracheal tube.

The patient is biting on the endotracheal tube Rationale Inserting an oral airway helps prevent the patient from biting on the oral endotracheal tube. The high-pressure alarm may sound because of decreased airway size, increased mucus secretions, or decreased compliance of the lungs, but none of these problems can be solved by the insertion of an oral airway. When the patient has increased mucus secretions, suction should be provided. When decreased compliance of the lungs is experienced, the nurse should evaluate the underlying cause and try to alleviate the problem.

The nurse is assessing a patient who is receiving mechanical ventilation with positive end-expiratory pressure (PEEP). Which findings would cause the nurse to suspect a left-sided tension pneumothorax? A. The patient has bloody sputum and expiratory wheezes. B. The chest caves in on inspiration and "puffs out" on expiration. C. The trachea is deviated to the right side, and cyanosis is present. D. The left lung field is dull to percussion with crackles on auscultation.

The trachea is deviated to the right side, and cyanosis is present Rationale Symptoms of tension pneumothorax include chest asymmetry, tracheal deviation toward the unaffected side, dyspnea, absent breath sounds, jugular venous distention (JVD), cyanosis, and hyperresonance to percussion over the affected area. Flail chest is manifested by paradoxical chest movement, which consists of "sucking inward" of the loose chest area during inspiration and puffing out of the same area during expiration. Open pneumothorax presents with decreased breath sounds, hyperresonance, and poor respiratory excursion on the affected side. Pulmonary contusion presents with hemoptysis, dullness to percussion, and crackles or wheezes.

A patient who had knee surgery 2 days ago now has extreme shortness of breath, agitation, and apprehension. A heart rate of 119 beats/min and a respiratory rate of 24 breaths/min with an oxygen saturation of 84% are also noted. Which condition would the nurse suspect?

Venous thromboemboli are a potential complication after orthopedic surgery. Shortness of breath, agitation, apprehension, tachycardia, and a decreased oxygen saturation are findings consistent with a pulmonary embolism. Anaphylaxis and bronchospasm are characterized by wheezing. Pneumothorax is characterized by absent breath sounds on the affected side.

Which drug is an antidote for warfarin?

Vit K

A patient who has a pulmonary embolism is very anxious. In which situation would the nurse expect the health care provider to prescribe sedation for the patient?

When the pt is mechanically ventilated Rationale A health care provider may prescribe sedation to a patient with pulmonary embolism who is mechanically ventilated. Even if the patient reports pain, is unable to sleep, or will not cooperate for diagnostic testing, sedation may result in hypoventilation, so it is contraindicated for this patient.

volutrauma

when excess volume of ventilation is delivered to only one lung

Oropharyngeal airway

used to prevent the tongue from occluding the airway or the patient from biting the endotracheal tube

Assist-control

ventilation continues to deliver a preset tidal volume, even when the pt's spontaneous breathing rate increases

SIMV

-synchronized intermittent mandatory ventilation -coordinates breathing between the ventilator and the patient and is not required in a patient with sleep apnea bc continuous flow is needed

Which step would the nurse consider first in the emergency approach to a patient with chest injuries? Airway Breathing Circulation Disability

Airway Rationale The first step in the ABC emergency approach to all chest injuries is to clear the patient's airway, followed by addressing breathing and circulation. Assessment of disability follows the other steps.

Which drug would the nurse expect to be prescribed for a patient experiencing massive pulmonary embolism who has shock symptoms?

Alteplase Fibrinolytic agents, such as alteplase, are used in the treatment of pulmonary embolism, specifically when the patient has shock and hemodynamic collapse.

Which patient is at high risk for developing a pulmonary embolism (PE)? A. 67-year-old man who works on a farm B. 45-year-old man admitted for a heart attack C. 23-year-old woman with a bleeding disorder D. 25-year-old woman who frequently flies internationally

25-year-old woman who frequently flies internationally Rationale People who engage in prolonged and frequent air travel are at high risk for PE. A 67-year-old man who works on a farm is not at high risk because he has an active lifestyle. A heart attack is usually caused by a thrombus or occlusion of the coronary arteries, not of the legs, where a venous clot could later become a PE. PE is a clotting disorder, not a bleeding disorder.

Which patient would the nurse monitor closely for respiratory failure? Select all that apply. One, some, or all responses may be correct. A. Patient with a brainstem tumor B. Patient with acute pancreatitis C. Patient with a T3 spinal cord injury D. Patient using patient-controlled analgesia E. Patient experiencing cocaine intoxication

A, B, C, D Rationale Pressure on the brainstem may depress respiratory function. Acute pancreatitis is a risk factor for acute respiratory distress syndrome (ARDS); abdominal distention also ensues, which can limit respiratory excursion. Opiates, which can depress the brainstem, present risk factors for respiratory failure. Patients with cervical and thoracic spinal cord injuries are at high risk for respiratory failure because spinal nerves that affect intercostal muscles are affected. All of these patients should be monitored closely for respiratory failure. Cocaine is a stimulant, which would not cause respiratory failure.

A postoperative patient is obese and reports smoking a pack of cigarettes a day. Which intervention would the nurse include in this patient's plan of care to help prevent venous thromboembolism? A. Teach the patient about smoking-cessation techniques. B. Assist with passive and active range-of-motion exercises. C. Elevate the patient's legs by placing pillows under the knees. D. Encourage the patient to take deep breaths and cough frequently.

Assist with passive and active range of motion exercises Rationale This patient is at risk for deep vein thrombosis (DVT) in the legs, which can cause pulmonary complications when a blood clot breaks loose and lodges in the lungs. Passive and active range-of-motion exercises can help prevent DVTs. Placing a pillow under the knees increases the risk for DVT because it puts pressure on the popliteal space. Coughing can help clear airways in patients who are not at risk for DVT, but coughing involves the Valsalva maneuver, which can increase the risk for clots. Smoking-cessation techniques are an important part of long-term management but will not help in the immediate time period to prevent clots.

Which assessment finding would the nurse expect in a patient with a tension pneumothorax? Dry, nonproductive cough Crackles in the lung bases Reduced breath sounds bilaterally Hyperresonant sounds on percussion

Hyperresonant sounds on percussion Rationale A common assessment finding in a patient with a tension pneumothorax is hyperresonant sounds on percussion. This occurs because of the trapped air in the pleural space. A dry cough, crackles over the affected area, and reduced breath sounds bilaterally are findings associated with a pulmonary contusion.

A patient with a pulmonary embolism is experiencing anxiety and asks the nurse for a sedative. Which risk would be increased by administering a sedative? A. Increased clotting B. Hypoventilation C. Hyperventilation D. Abnormal bleeding

Hypoventilation Rationale Although a sedative can help manage a patient's anxiety, a health care provider is unlikely to prescribe it to a patient with a pulmonary embolism because sedatives carry the risk for hypoventilation as a side effect. Sedative agents do not carry a risk for increasing clots. Anticoagulants, not sedatives, may cause abnormal bleeding. Sedative agents slow, not quicken, breathing, so they are unlikely to cause hyperventilation.

Which patient condition indicates a need for immediate intubation? A. Oxygen (O 2) saturation of 90% B. Difficulty swallowing oral secretions C. Thick, purulent secretions and crackles D. Hypoventilation and decreased breath sounds

Hypoventilation and decreased breath sounds Rationale Intubation may be indicated for the patient who is hypoventilating and has decreased breath sounds. Suctioning, rather than intubation, is indicated for difficulty swallowing secretions and for thick, purulent secretions and crackles (consistent with pneumonia). Intubation is indicated for the patient with an O 2 saturation of less than 90% and other symptoms of hypoxemia or hypercarbia if oxygen supplementation is not effective.

Which condition is consistent with an x-ray report of three adjacent ribs each fractured in three different places? Flail chest Pulmonary contusion Tension pneumothorax Tracheobronchial trauma

Flail chest Rationale Flail chest appears in CT as the fracture of at least three neighboring ribs in two or more places. The chest x-ray of a patient with a pulmonary contusion reveals hazy opacity in the lobes or parenchyma. A tension pneumothorax is indicated by the asymmetry of the thorax in the x-ray. In tracheobronchial trauma, the chest x-ray shows a tracheobronchial tear.

Which patient problem would be the focus of initial nursing interventions for a patient admitted with a pulmonary embolism (PE)? A. Risk for impaired skin integrity B. Insufficient knowledge related to the cause of PE C. Hypoxemia related to ventilation-perfusion mismatch D. Inadequate nutrition related to food-drug interactions

Hypoxemia related to ventilation -perfusion mismatch Rationale Restoring adequate oxygenation and tissue perfusion takes priority when a patient presents with a PE. Although nutrition must be addressed, priorities include airway, breathing, and circulation. Interventions for skin integrity will be addressed after the patient's oxygenation is stabilized. Education as to the cause of PE must be postponed until oxygenation and hemodynamic stability occur.

Which condition manifests as delirium in patients on mechanical ventilation?

ICU psychosis -use of mechanical ventilation for a patient in the ICU can cause anxiety and delirium

A patient who was just transferred to the ICU after developing a pulmonary embolism is receiving anticoagulant therapy and oxygen. The nurse notes clear breath sounds, an oxygen saturation of 95%, and a heart rate of 78 beats/min. The patient reports feeling scared that something bad will happen. Which action would the nurse take? A. Request a prescription for an antianxiety medication. B. Reassure the patient that the treatment is working. C. Suggest that the patient take deep breaths to relax. D. Increase the oxygen flow to improve oxygen saturation.

Reassure the patient that the treatment is working Rationale The patient with a pulmonary embolism is receiving appropriate treatment and has stable vital signs, so the nurse should stay with the patient and provide assurance that the measures are working. Anxiety is a common response to pulmonary embolism, even when the patient is stable. The patient has adequate oxygen saturation, so increasing the oxygen flow is not indicated. If reassurance is not effective, an antianxiety medication may be necessary at a later time. The patient may not be able to take deep breaths, so this is not recommended as a relaxation technique.

Which intervention would the nurse plan for reducing anxiety in a patient with a pulmonary embolism (PE)? A. Offer the patient a mild sedative. B. Allow a family member to remain in the room. C. Remain with the patient, and provide oxygen. D. Have the patient breathe into a brown paper bag.

Remain with pt and provide oxygen Rationale The underlying cause for anxiety with a PE is hypoxemia, which will be alleviated by oxygen; remaining with the patient in distress is appropriate. Rebreathing from a brown bag is an intervention that increases partial pressure of arterial carbon dioxide (Paco 2) during hyperventilation, as in a panic attack; it will not provide needed oxygen. Sedation or allowing a family member to stay may calm the patient but will not improve oxygenation.

The nurse is explaining thrombolytic therapy to a patient. Which information would the nurse include? A. "You will receive a dose of enoxaparin IM for 3 days." B. "Therapy with warfarin is effective when your international normalized ratio (INR) is between 2 and 3." C. "If bleeding develops, we will give you platelets to reverse the anticoagulant." D. "As soon as the health care provider prescribes warfarin, we will stop the IV heparin."

Therapy with warfarin is effective when your INR is between 2 and 3 Rationale The INR, a measurement of anticoagulation with warfarin, is in the therapeutic range between 2 and 3. Enoxaparin is a low-molecular-weight heparin that is usually given by the subcutaneous route. Heparin and warfarin are overlapped until the INR is in the therapeutic range; then the heparin can be discontinued. Fresh-frozen plasma is used as an antidote for anticoagulant therapy, not platelets.

A patient who is intubated and on mechanical ventilation develops respiratory distress. Which action would the nurse take first? A. Arrange to have arterial blood gases drawn. B. Activate the hospital's Rapid Response Team. C. Notify the health care provider, and monitor the patient's saturated arterial oxygen (Sao 2). D. Ventilate the patient using a bag-valve-mask device.

Ventilate the patient using a bag valve mask device Rationale The priority is to provide ventilation using a bag-valve-mask device to determine if the problem is with the patient or the ventilator. This information is necessary before calling the health care provider or the Rapid Response Team. Arterial blood gases may provide useful information later but will not help with determining the immediate actions.

A patient reports a sudden onset of shortness of breath; a sharp, stabbing chest pain; and a feeling of apprehension. The nurse auscultates crackles in both lungs and assesses tachypnea and an oxygen saturation of 88%. After notifying the Rapid Response Team, the nurse would take which action next? A. Prepare to give IV heparin and obtain venous access. B. Reassure the patient, and continue to assess for other symptoms. C. Elevate the head of the bed, and assemble oxygen delivery equipment. D. Prepare the patient for a chest x-ray, and apply telemetry monitoring equipment.

Elevate the head of the bed, and assemble oxygen delivery equipment Rationale Shortness of breath; a sharp, stabbing chest pain; and a feeling of apprehension are symptoms of pulmonary embolism. The nurse's initial intervention after activating the Rapid Response Team will be to elevate the head of the bed and prepare to give oxygen. Heparin, venous access, chest x-ray, and telemetry require prescriptions. Reassurance and assessment of symptoms are ongoing.

Which blood gas result would the nurse anticipate early in the course of pulmonary embolism (PE)? pH 7.24, partial pressure of arterial carbon dioxide (PaCo 2) 55 mm Hg, bicarbonate (HCO 3 -) 26 mEq/L, partial pressure of arterial oxygen (Pao 2) 56 mm Hg pH 7.46, PaCo 2 30 mm Hg, HCO 3 - 26 mEq/L, Pao 2 68 mm Hg pH 7.35, PaCo 2 45 mm Hg, HCO 3 - 24 mEq/L, Pao 2 80 mm Hg pH 7.47, PaCo 2 35 mm Hg, HCO - 30 mEq/L, Pao 2 75 mm Hg

pH 7.46, PaCo 2 30 mm Hg, HCO 3 - 26 mEq/L, Pao 2 68 mm Hg Rationale Hyperventilation triggered by hypoxia and pain first leads to respiratory alkalosis, indicated by a low PaCo 2 of 30 and a high pH of 7.46. No compensation is present because the HCO 3- of 26 is normal and hypoxemia is present, consistent with PE. A pH of 7.24 is acidotic, a Pao 2 of 56 reflects hypoxemia, and no compensation is present with a normal HCO 3- of 26; this blood would be found in a person in acute respiratory failure because of hypoventilation and hypoxemia. A pH between 7.35 and 7.45, PaCo 2 of 35 to 45, HCO 3- of 22 to 26, and Pao 2 greater than 75 all reflect a normal blood gas. A pH of 7.47 and an HCO 3- of 30 are alkalotic, indicating metabolic alkalosis; a PaCo 2 of 35 is normal (indicating lack of compensation), and a Pao 2 of 75 is normal.

The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who is on mechanical ventilation. Which plan stated by the nurse needs correction? "I will provide the patient with a carbohydrate-rich enteral formula." "I will administer proton pump inhibitors to the patient." "I will provide the patient with formulas that have a high fat content." "I will regularly monitor the calcium and magnesium levels of the patient."

"I will provide the patient with a carbohydrate-rich enteral formula." Rationale Patients with COPD require a reduction of dietary carbohydrates. During metabolism, carbohydrates are broken down to glucose, which then produces energy, carbon dioxide, and water. Excess carbohydrate loads increase carbon dioxide production that the patient cannot exhale, resulting in hypercarbic respiratory failure. Administering proton pump inhibitors is beneficial to the patient to prevent stress ulcers because the patient may be unable to tolerate carbohydrates-rich nutrition if there are peptic ulcerations. Providing the patient with formulas that have high fat content will combat imbalances in nutrition. Monitoring electrolytes is useful in detecting any electrolyte imbalances in patients receiving enteral or parenteral nutrition.

Which patient outcome is the priority during the initial phase of treatment for a pulmonary embolism? A. Reduced level of anxiety B. Effective coping strategies C. Free from bleeding episodes D. Adequate gas exchange

Adequate gas exchange Rationale During the initial phase of treatment, oxygenation and gas exchange are the primary concerns. After anticoagulant therapy is initiated, and for the duration of anticoagulant therapy, bleeding is a concern. Anxiety and coping are a concern at all times but do not represent life-threatening problems.

A patient develops distended neck veins, severe dyspnea, cyanosis, and syncope. The patient is hypoxic and hypotensive and has an abnormal electrocardiogram. The Rapid Response Team arrives. Which medication would the nurse anticipate will be prescribed immediately? Alteplase Warfarin Clopidogrel Low-molecular-weight heparin

Alteplase Rationale This patient is displaying symptoms of a pulmonary embolism (PE). Patients who are hemodynamically unstable will need fibrinolytic drugs to break up the clot causing the PE. Heparin is used when the patient is stable to prevent the clot from getting larger. Clopidogrel is used to prevent PE in nonhospitalized patients. Warfarin is used after the patient is stable as it generally takes 72 hours to produce anticoagulation.

Which action is a priority for a nurse coming on shift to care for a ventilated patient who is sedated? Select all that apply. One, some, or all responses may be correct. A. Ask family members to leave. B. Listen for bilateral breath sounds. C. Confirm alarms and ventilator settings. D. Assess the patient's color and respirations. E. Ensure that the tube cuff is inflated and is in the proper position. F. Provide routine tracheotomy and endotracheotomy care and mouth care.

B, C, D, E Rationale The first priority when caring for a critically ill patient receiving mechanical ventilation is to assess airway and breathing. Alarm settings should be confirmed each shift and more frequently if necessary. Confirming that the patient cannot speak ensures that air is going through the endotracheal tube and not around it. Auscultating for equal bilateral breath sounds assists in confirming that the tube is above the carina. Having family visitors remain with the patient may promote comfort and prevent confusion. Routine tracheostomy care is performed according to schedule and PRN, not necessarily as part of an initial assessment.

Which action describes paradoxical chest wall movement? Bilateral separation of the ribs from their cartilage Deviation of the trachea away from the side of the injury Forceful entry of air into the chest cavity causing lung collapse Inward movement of the thorax during inspiration

Inward movement of the thorax during inspiration Rationale Flail chest results in paradoxical chest wall movement. It is the inward movement of the thorax during inspiration with outward movement during expiration. Bilateral separation of the ribs from their cartilage causes flail chest. Tension pneumothorax deviates the trachea away from the side of the injury. Forceful entry of air into the chest cavity causing collapse of the affected lung is related to tension pneumothorax.

Which information would the nurse communicate to the family of a patient who is receiving mechanical ventilation? A. "Paralytic and sedative medications help decrease the demand for oxygen." B. "Suctioning is important to remove organisms from the lower airway." C. "We are encouraging oral and IV fluids to keep your loved one hydrated." D. "Sedation is needed so your loved one does not remove the breathing tube."

Paralytic and sedative meds help decrease the demand for oxygen Rationale Paralytics and sedation decrease oxygen demand. Sedation is needed more for its effects on oxygenation than to prevent the patient from removing the endotracheal tube. Suctioning is performed to maintain airway patency. Oral fluids would increase the risk for aspiration and pneumonia while an artificial airway and mechanical ventilation are in use. p. 596

A patient with pneumonia has a productive cough, dyspnea with ambulation, and increased work of breathing with use of accessory muscles. The patient's oxygen saturation is 92%, and arterial blood gas monitoring reveals a partial pressure of arterial oxygen (PaO 2) of 88 mm Hg. Which condition would the nurse report to the health care provider? Ventilatory failure Respiratory failure Respiratory distress Oxygenation failure

Respiratory distress Rationale This patient has increased work of breathing and dyspnea characteristic of respiratory distress but is still compensating to maintain oxygenation as evidenced by an oxygen saturation of 92% and a PaO 2 of 88 mm Hg. Ventilatory failure is a rise in PaCO 2 (hypercapnia) that occurs when the respiratory load can no longer be supported by the strength or activity of the system. The PaO 2 in respiratory failure would be less than 60 mm Hg. Oxygen failure (hypoxemic respiratory failure) means that you don't have enough oxygen in your blood, but your levels of carbon dioxide are close to normal.

A 154-lb (70-kg) patient receiving manual ventilation is becoming agitated and restless. The nurse determines that the endotracheal tube is in place and notes an oxygen saturation of 97%. Ventilator settings include a pressure of 12 cm H 2O, a tidal volume of 600 mL, and a flow rate of 30 L/min. Which action would the nurse take? A. Reassure the patient that this is typical of "ICU psychosis." B. Contact the health care provider to discuss increasing the tidal volume. C. Increase the oxygen flow rate, and reassess the patient. D. Notify the health care provider that this patient is ready to be weaned from the ventilator.

Increase oxygen, and reassess the patient Rationale The first step when a patient becomes agitated or restless, after checking the ventilator settings, is to increase the flow rate and then reassess the patient. This patient's tidal volume is appropriate. Patients who are ready to be weaned from the ventilator make respiratory efforts against the ventilator. These are not necessarily signs of delirium typical of ICU psychosis, and the nurse should first attempt to evaluate the cause of the agitation.

A patient who is a lifetime smoker and obese and has a previous history of thromboembolism is preparing to have major surgery that will require prolonged immobility. Past treatments with anticoagulant medications caused serious bleeding. Which management strategy would the nurse expect the health team to recommend for this patient? A. Embolectomy B. Fibrinolytic therapy C. Anticoagulant therapy D. Inferior vena cava filtration

Inferior vena cava filtration Rationale High-risk patients with a previous history of thromboembolism and bleeding with anticoagulant therapy can have a vena cava filtration device placed to prevent clots from reaching the lungs. Anticoagulant therapy is contraindicated in this patient because of the previous history of bleeding. Embolectomy is a surgical procedure to remove clots when a massive clot or multiple clots are present, causing shock. Fibrinolytic therapy also carries a risk for bleeding.

When caring for a patient who is receiving mechanical ventilation, the nurse hears the high-pressure alarm. Which action would the nurse take first? Assess the set tidal volume. Call the respiratory therapist. Check the ventilator alarm settings. Listen to the patient's breath sounds.

Listen to the patient's breath sounds Rationale A typical reason for the high-pressure alarm to sound is the need for suctioning or tension pneumothorax. The nurse should begin the assessment with the patient, not with the ventilator. Although an excessively high tidal volume could contribute to sounding of the high-pressure alarm, assessment always begins with the patient. The professional nurse possesses the skill to assess ventilator alarms; waiting for the respiratory therapist delays intervention.

Which activity would the nurse recommend that the patient avoid for several hours after extubation? A. Using supplemental oxygen B. Lying supine to rest C. Using the spirometer D. Taking deep breaths

Lying supine to rest Rationale The patient should sit in a semi-Fowler position rather than lying down for resting after extubation because it reduces the risk for fluid accumulation and aspiration immediately after extubation. The patient who has recently been extubated is likely to require supplemental oxygen. Using the spirometer every 2 hours promotes gas exchange and is advisable. Taking deep breaths every half-hour improves gas exchange.

A patient with an acute exacerbation of asthma exhibits wheezing, dyspnea, and intercostal retractions. An arterial blood gas shows partial pressure of arterial oxygen (PaO 2) of 55 mm Hg, a partial pressure of arterial carbon dioxide (PaCO 2) of 50 mm Hg, and a pH of 7.25. Which condition is this patient experiencing? A. Ventilatory failure B. Oxygenation failure C. Acute respiratory distress syndrome D. Ventilatory and oxygenation failure

Ventilatory and oxygenation failure Rationale Patients with chronic obstructive diseases such as asthma may develop oxygenation failure because of diseased airways and subsequent increased work of breathing that progresses to ventilatory failure. This patient is demonstrating hypercapnia and hypoxia and acidosis. Ventilatory failure causes hypercapnia. Oxygenation failure causes hypoxemia. Acute respiratory distress syndrome is a cause of oxygenation failure.

In which order do physiologic changes lead to acute respiratory distress syndrome (ARDS)?

1. Pulmonary contusion 2. Systemic inflammatory response 3. Reduced gas exchange 4. Progressive hypoxemia Rationale Trauma such as pulmonary contusion results in a systemic inflammatory response that reduces gas exchange at the alveolar-capillary membrane. The patient may become progressively hypoxemic.

Which amount of initial blood loss may necessitate an open thoracotomy in a patient with a hemothorax? 250 mL 500 mL 750 mL 1000 mL

1000 mL Rationale The minimum amount of blood loss required to perform a thoracotomy in a patient with a hemothorax is 1000 mL. Blood losses of 250 mL, 500 mL, or 750 mL do not indicate the need for a thoracotomy.

Which statement by a nurse about potential assessment findings for a patient with a pneumothorax indicates a need for further teaching? "Hyporesonance will be noted on percussion." "On auscultation, decreased breath sounds will be noted." "The involved side of the chest will move poorly with respiration." "Deviation of trachea away from side of injury may be noticed."

"Hyporesonance will be noted on percussion." Rationale Assessment findings of a pneumothorax involve hyperresonance on percussion. Hyporesonance may indicate an infection of the lungs. Reduced breath sounds on auscultation indicate reduced air entry into the lungs. Prominence of the involved side of the chest, which moves poorly with respiration, is seen in a pneumothorax. Deviation of the trachea away from the side of injury may be observed with a tension pneumothorax.

Which statement by a nurse about potential assessment findings for a patient with a pneumothorax indicates a need for further teaching? c "On auscultation, decreased breath sounds will be noted." "The involved side of the chest will move poorly with respiration." "Deviation of trachea away from side of injury may be noticed."

"Hyporesonance will be noted on percussion." Rationale Assessment findings of a pneumothorax involve hyperresonance on percussion. Hyporesonance may indicate an infection of the lungs. Reduced breath sounds on auscultation indicate reduced air entry into the lungs. Prominence of the involved side of the chest, which moves poorly with respiration, is seen in a pneumothorax. Deviation of the trachea away from the side of injury may be observed with a tension pneumothorax.

In which order do physiologic changes occur with tension pneumothorax?

1. Air is forced into the chest cavity, increasing the pressure. 2. Major blood vessels are compressed. 3. Venous return is limited. 4. Cardiac filling and cardiac output are decreased. Rationale Tension pneumothorax is a life-threatening condition that may lead to death. Air is forced into the chest cavity, and the pressure increases. This increased pressure compresses the blood vessels, resulting in the limiting of blood return. Finally, there is a decrease in the cardiac filling as well as the cardiac output.

In which order do physiologic changes occur in a patient with pulmonary contusion?

1. Hemorrhage and edema 2. Reduction in lung movement 3. Hypoxia and dyspnea 4. Hazy opacity in the lobes or lung parenchyma Rationale Respiratory failure may develop in a patient with pulmonary contusion. Hemorrhage and edema occur in and between the alveoli first, thereby reducing both lung movement and the area available for gas exchange. The patient will then experience hypoxia and dyspnea. Hazy opacity in the lobes or lung parenchyma can develop over time.

In which order would physiologic changes related to a pneumothorax occur?

1. Occurrence of chest injury 2. Entry of air into the pleural space 3. Rise in the chest pressure 4. Reduction in the vital capacity Rationale A pneumothorax is associated with chest injury or trauma that causes air to enter the pleural space. Large amounts of air in the pleural space result in increased pressure in the chest, reducing the vital capacity of the lungs.

In which order do physiologic changes lead to acute respiratory distress syndrome (ARDS)?

1. Pulmonary contusion 2. Systemic inflammatory response 3. Reduced gas exchange 4. Progressive hypoxemia

A patient transported to the emergency department after a motor vehicle crash has a heart rate of 115 beats/min, blood pressure of 88/59 mm Hg, shortness of breath, cyanosis, and paradoxical chest movement. Which action would the nurse take first? Administer oxygen. Give analgesic medications. Suction secretions from the airway. Turn the patient to the unaffected side.

Administer oxygen Rationale Patients with a flail chest are initially treated with oxygen, pain management, and promotion of lung expansion through deep breathing, positioning, and airway clearance. Oxygen is always administered first.

Which treatment is the focus during the management of an uncomplicated rib fracture? Splinting the chest Administering analgesics Stabilizing the chest surgically Applying positive-pressure ventilation

Administering analgesics Rationale An uncomplicated rib fracture can be managed by the administration of analgesics. Splinting the chest by tape or any other material is not preferred. Surgical stabilization is indicated for extreme cases of flail chest. Positive-pressure ventilation is usually a preferred treatment modality to stabilize a flail chest.

A 5-foot 2-inch tall, 38-year-old patient who weighs 110 lb (50 kg) is being mechanically ventilated at a tidal volume of 400 mL and a respiratory rate of 16 breaths/min. The most recent arterial blood gas (ABG) results are: pH = 7.32; partial pressure of arterial oxygen (Pao 2) = 85 mm Hg; and partial pressure of arterial carbon dioxide (PaCo 2) = 55 mm Hg. Which action would the nurse take? A. Continue to monitor the patient's currently stable status. B. Request an order to begin weaning the patient from the ventilator. C. Notify the health care health care provider about the need for sodium bicarbonate. D. Auscultate breath sounds to check endotracheal tube placement.

Auscultate breath sounds to check endotracheal tube placement Rationale Tidal volume may be calculated by multiplying the patient's body weight in kilograms by 7 or 10 or by adding a zero to the weight in kilograms. This patient weighs 110 lb (50 kg), so an adequate tidal volume would be 350 to 500 mL. The settings of the ventilator are correct, but the patient continues to exhibit respiratory acidosis as evidenced by a low pH, low Pao 2, and elevated PaCo 2. The nurse should auscultate breath sounds and check placement of the endotracheal tube to see if both lungs are being ventilated. Because the patient has respiratory acidosis, the patient is not compensating and not stable. Until the nurse completely assesses the patient and ensures adequate ventilation, requesting sodium bicarbonate is not warranted. Weaning is not begun until patients are stable and making attempts to breathe on their own.

Which finding in a CT report of a patient with chest trauma indicates a flail chest? Hemorrhage and edema Deviation of trachea away from the side of injury Tear in the tracheobronchial tree Bilateral separation of ribs from cartilage

Bilateral separation of ribs from cartilage Rationale A flail chest may occur because of bilateral separation of the ribs from the cartilage connections, which would be revealed in the CT scan. A pneumothorax is associated with the deviation of trachea away from the side of injury. The CT scan also reveals hemorrhage and edema in patients with pulmonary contusion, but bilateral rib separation from the cartilage is not associated with pulmonary contusion. Tracheobronchial trauma is associated with a tear in the tracheobronchial tree of the patient's respiratory system.

Which finding indicates that the endotracheal tube remains correctly placed in the patient's trachea and is not in the esophagus? A. Breath sounds are present equally over bilateral lung fields. B. Oxygen saturation by pulse oximetry is greater than 85%. C. A suction catheter is easily passed through the endotracheal tube. D. No air is heard in the stomach when auscultated with a stethoscope.

Breath sounds are present equally over bilateral lung fields Rationale Bilateral positive breath sounds indicate the endotracheal tube is in the proper placement. If breath sounds are heard on the right but not the left, the breathing tube may be in the right mainstem bronchus and may need to be retracted until breath sounds are heard equally. The gold standard for endotracheal tube placement verification is a chest x-ray. If the endotracheal tube was in the esophagus or stomach, breath sounds would be heard over the stomach rather than the bilateral lung fields. Other indications of proper tube placement include positive end-tidal carbon dioxide (CO 2) readings and condensation in the tube. The fact that air cannot be heard in the stomach or that a suction catheter is easily passed are not conclusive assessments of a correctly placed endotracheal tube. Although an increase in oxygen saturation after intubation and ventilation indicates that the patient has improved oxygenation, the saturation value alone does not assure correct tube location.

Which statement is true regarding the management of patients with a hemothorax? Select all that apply. One, some, or all responses may be correct. Only a single chest x-ray is necessary. Close monitoring of chest tube drainage is needed. Blood in the pleural spaces is confirmed by a chest x-ray. Blood lost through the chest drainage system can be infused back. A single chest tube would be needed for emptying blood from pleural space.

Close monitoring of chest tube drainage is needed. Blood lost through the chest drainage system can be infused back. Rationale Chest tube drainage should be monitored closely for any blood loss. This would help in determining the effectiveness of treatment. Blood lost through chest drainage can be infused back into the patient if needed. Serial chest x-rays should be performed to help determine the effectiveness of the treatment. Blood in the pleural space can be viewed in the chest x-ray, but for confirmation, a thoracentesis should be performed. Multiple chest tubes may be needed for emptying blood from the pleural space.

Which findings would support that a patient may have a tension pneumothorax? Tachycardia and hypotension Cyanosis and distended neck veins Massive air leaks and tracheal lacerations Wheezes and crackles on auscultation

Cyanosis and distended neck veins Rationale The assessment findings of a tension pneumothorax include cyanosis and distended neck veins. A flail chest may develop as a complication of cardiopulmonary resuscitation and may manifest as cyanosis, dyspnea, tachycardia, and hypotension. Subcutaneous emphysema and air leaks may occur in patients with tracheal lacerations. Wheezes and crackles on auscultation may indicate edema or an infectious process in the airways.

Which finding would lead the nurse to suspect the patient has a tension pneumothorax? Select all that apply. One, some, or all responses may be correct. Stridor Cyanosis Distended neck veins Paradoxical chest movements Hyperresonant sounds on percussion

Cyanosis, Distended neck veins, Hyperresonant sounds on precussion Rationale Cyanosis occurs in patients with chest trauma because of hypoxia. Distended neck veins are seen in patients with a tension pneumothorax because of high pressure in the thorax. Hyperresonant sounds on percussion over the affected area are observed in a patient with a tension pneumothorax. Stridor is seen in patients with tracheobronchial trauma because of upper airway tract obstructions. Paradoxical chest movements are characteristic of a flail chest.

Which finding indicates that a patient has a flail chest? Select all that apply. One, some, or all responses may be correct. Cyanosis Dry cough Tachycardia Pleuritic pain Subcutaneous emphysema Paradoxic chest movement

Cyanosis, Tachycardia, Paradoxic chest movement Rationale A person with a flail chest typically presents with cyanosis, paradoxic chest movement, dyspnea, and tachypnea. A pulmonary contusion manifests as dry cough, tachycardia, tachypnea, and dullness to percussion. A pneumothorax manifests as pleuritic pain, subcutaneous emphysema, and tachypnea.

Which complication would the nurse anticipate for a patient who splints fractured ribs? Select all that apply. One, some, or all responses may be correct. Increased pain Increased risk for flail chest Decreased breathing depth Increased risk for a pneumothorax Ineffective clearance of secretions

Decreased breathing depth Ineffective clearance of secretions Rationale Complications associated with splinting fractured ribs includes decreased breathing depth and ineffective clearance of secretions. A patient splints the fracture to decrease pain. Flail chest and pneumothorax are not risk factors of splinting fractured ribs.

The critical care nurse is caring for a patient with a flail chest. Which intervention would the nurse include in the plan of care for this patient? Select all that apply. One, some, or all responses may be correct. Antibiotics Deep breathing Tracheal suction Pain management Humidified oxygen

Deep breathing Tracheal suction Pain management Humidified oxygen Rationale Expected nursing interventions for a patient with a flail chest who has been stabilized in the critical care unit should include deep breathing, tracheal suction, pain management, and humidified oxygen. Tracheal suctioning should be performed as needed to clear secretions. Antibiotics are indicated for pneumonia.

The critical care nurse is caring for a patient with a flail chest. Which intervention would the nurse include in the plan of care for this patient? Select all that apply. One, some, or all responses may be correct. Antibiotics Deep breathing Tracheal suction Pain management Humidified oxygen

Deep breathing Tracheal suction Pain management Humidified oxygen Rationale Expected nursing interventions for a patient with a flail chest who has been stabilized in the critical care unit should include deep breathing, tracheal suction, pain management, and humidified oxygen. Tracheal suctioning should be performed as needed to clear secretions. Antibiotics are indicated for pneumonia.

Which assessment finding is consistent with the patient having a large pneumothorax? Dull percussion notes Paradoxic chest movement Increased breath sounds on auscultation Deviated trachea away from the side of injury

Deviated trachea away from the side of injury Rationale In patients with a pneumothorax, the trachea deviates away from the affected side. Hyperresonance is noticed on percussion. Dull sounds on percussion are noticed in patients with a pulmonary contusion. Paradoxic chest movements are a characteristic feature of flail chest. Breath sounds are decreased on auscultation in patients with a pneumothorax.

Which assessment finding would the nurse expect in a patient with a tension pneumothorax? Select all that apply. One, some, or all responses may be correct. Distended neck veins Hemodynamic instability Dullness to percussion Extreme respiratory distress and cyanosis Prominence of the involved side of the chest Deviation of the trachea away from the midline

Distended neck veins Hemodynamic instability Extreme respiratory distress and cyanosis Prominence of the involved side of the chest Deviation of the trachea away from the midline Rationale Assessment findings specific to tension pneumothorax include distended neck veins, hemodynamic instability, and extreme respiratory distress and cyanosis. Prominence of the involved side of the chest and deviation of the trachea away from the side of injury toward the unaffected side occurs in severe pneumothorax and tension pneumothorax. Pneumothorax causes hyperresonance on percussion, while hemothorax causes dullness to percussion.

Which finding may signify a pulmonary contusion in a patient who was in a motor vehicle crash? Select all that apply. One, some, or all responses may be correct. Dry cough Hemoptysis Bradycardia Tachycardia Hyperresonant to percussion

Dry cough, Tachycardia Rationale Patients with a pulmonary contusion have a dry cough and tachycardia. Hemoptysis may occur with a pulmonary embolism. Bradycardia does not manifest in a pulmonary contusion. The sound of percussion in a patient with a pulmonary contusion is always dull. Hyperresonance on percussion occurs in patients with a pneumothorax.

Which condition is illustrated in the figure that depicts inspiration and expiration? Flail chest Hemothorax Pneumothorax Tension pneumothorax

Flail chest Rationale In a flail chest, inward movement of the thorax during inspiration and outward movement during expiration are observed. In a hemothorax, blood loss is seen. In a pneumothorax, air enters into the pleural space because of chest injury. In a tension pneumothorax, air that enters into the pleural space during inspiration does not exit during expiration.

Which parameter would the nurse monitor in a patient with a flail chest? Select all that apply. One, some, or all responses may be correct. Blood loss Fluid intake Blood pressure Electrolyte balance Chest tube output

Fluid intake, Blood pressure, Electrolyte balance Rationale Patients with a flail chest are at increased risk for hypovolemia or shock. Therefore fluid intake, vital signs such as blood pressure, and electrolyte balance should be monitored in this patient. This helps to manage the patient's condition immediately. Monitoring for blood loss or chest tube output would be beneficial when managing patients who have sustained a hemothorax.

Which statement is true regarding uncomplicated rib fractures? Select all that apply. One, some, or all responses may be correct. Fractured ribs reunite spontaneously. Intercostal nerve block can be useful for severe pain. Splinting the ribs with tape is recommended. Decreasing the pain helps maintain ventilation. Rib fractures increase the risk for deep chest injury.

Fractured ribs reunite spontaneously. Intercostal nerve block can be useful for severe pain. Decreasing the pain helps maintain ventilation. Rib fractures increase the risk for deep chest injury. Rationale Management of uncomplicated rib fractures is simple because the fractured ribs reunite spontaneously. The patient experiences pain while breathing, which can be managed with pain medication. When ribs are fractured, the force also drives bone ends into the chest, so there is a risk for deep chest injury, such as a contusion, pneumothorax, or hemothorax. Patients with uncomplicated rib fractures may have severe pain, so an intercostal nerve block is an option in managing the pain. Splinting the ribs by wrapping the chest with tape reduces breathing depth and clearance of secretion and is not recommended.

Which type of chest trauma produces a dull sound on percussion of the affected side? Rib fracture Hemothorax Pneumothorax Tension pneumothorax

Hemothorax Rationale A dull sound on percussion of the affected side is a typical feature of a hemothorax. Rib fractures do not alter the percussion tone. A pneumothorax or tension pneumothorax produce a hyperresonant tone on percussion.

Which condition may require the use of a chest tube to drain fluid from the pleura? Flail chest Hemothorax Pneumothorax Tension pneumothorax

Hemothorax Rationale Chest tubes may be used in a patient with a hemothorax to empty the pleural space of accumulated blood. A pneumothorax and a tension pneumothorax may require a chest tube for removal of air from the pleural space. A flail chest does not require a chest tube unless other injuries are also present.

The nurse is caring for a patient who was injured while playing football. The patient has reduced breath sounds with chest prominence on one side and hyperresonance to percussion. For which procedure would the nurse expect to prepare the patient? Intercostal nerve block Antibiotic administration Immediate needle thoracostomy Mechanical ventilation

Immediate needle thoracostomy Rationale The patient with reduced breath sounds and chest prominence on one side and hyperresonance on percussion most likely has a tension pneumothorax, which is commonly caused by blunt trauma to the chest. Tension pneumothorax is managed with immediate needle thoracostomy, followed by insertion of a chest tube. An intercostal nerve block is indicated for severe pain from rib fractures. Antibiotics are indicated for pneumonia. Mechanical ventilation is used to manage severe flail chest with respiratory distress.

A patient has severe pain from three rib fractures after a workplace accident. Which intervention would the nurse suggest to the health care provider? Intercostal nerve block Mechanical ventilation Splinting the ribs with tape Administering opioid analgesics

Intercostal nerve block Rationale Patients with severe pain often do not take deep breaths and thus do not maintain adequate ventilation. An intercostal nerve block is used for severe pain. Opioid analgesics suppress respiration and should be avoided. Splinting with tape is not done unless the fracture is complex, when seven or more ribs are involved, or if a flail chest is present. Mechanical ventilation is used as a last intervention after others have been attempted.

A patient who was physically assaulted has rib fractures. The patient has severe pain upon movement and splints the chest defensively. For which procedure would the nurse expect to prepare the patient? Intercostal nerve block Antibiotic administration Immediate needle thoracostomy followed by insertion of a chest tube Mechanical ventilation

Intercostal nerve block Rationale The patient with severe pain upon movement who splints the chest defensively most likely has a rib fracture, which is managed with an intercostal nerve block for pain. Antibiotics are indicated for pneumonia. A tension pneumothorax is managed with an immediate needle thoracostomy, followed by insertion of a chest tube. Mechanical ventilation is used to manage severe flail chest with respiratory distress.

Which procedure would the nurse anticipate the health care provider will perform to treat a suspected tension pneumothorax in a patient with chest trauma? Intercostal block Cricothyroidotomy Bronchoscopy Needle thoracostomy

Needle thoracostomy Rationale A tension pneumothorax is a life-threatening complication in which air escapes into the chest cavity, causing a complete collapse of the affected lung. A large-bore needle thoracostomy is the initial and immediate intervention in this situation. Thoracostomy is followed by placing chest tubes. An intercostal block is used to manage pain from serious rib fractures. A cricothyroidotomy is performed to establish an airway in cases of tracheobronchial trauma. A bronchoscopy is performed for diagnostic purposes or to remove something from the airway such as mucus or a foreign object.

Which initial radiographic findings would the nurse expect in a patient with a pulmonary contusion? No opacity in the lobes or parenchyma Hazy opacity in the lobes or parenchyma Highly dense opacity in the lobes or parenchyma Moderately dense opacity in the lobes or parenchyma

No opacity in the lobes or parenchyma Rationale Initial assessment of the chest x-ray may not reveal any abnormalities, but a hazy opacity in the lobes or parenchyma may develop over several days, and the density may increase as time progresses. Highly dense opacity or moderately dense opacity is seen at later stages of a pulmonary contusion as the condition of the patient progresses.

A patient on mechanical ventilation has a sudden onset of respiratory distress. The nurse auscultates absent breath sounds on the right side and observes a shift of the trachea to the left. The patient is cyanotic and has distended neck veins. Which is the priority action the nurse would take? Notify the Rapid Response Team. Request an order for arterial blood gases. Assess for correct placement of the endotracheal tube. Remove the ventilator, and manually ventilate the patient.

Notify the Rapid Response Team Rationale This patient has symptoms of a tension pneumothorax, which may quickly be fatal if not treated appropriately. The initial action is to notify the Rapid Response Team. Endotracheal tubes generally become displaced into the right mainstem bronchus, causing absent breath sounds on the left. The other actions may be performed when the Rapid Response Team arrives.

Which factor contributes to a patient with a flail chest developing atelectasis and pneumonia? Splinting the chest Performing tracheal suction Elevating the head of the patient's bed Providing positive-pressure ventilation

Splinting the chest Rationale Splinting is contraindicated in patients with a flail chest as it may further reduce the ability to exert the extra effort to breathe and may contribute later to the failure to wean off mechanical ventilation. Performing tracheal suction is beneficial in clearing nasal secretions. Elevating the head of the patient's bed does not interrupt the patient's capacity to wean from the ventilator. Providing positive-pressure ventilation is indicated for the stabilization of flail chest and helps to prevent atelectasis.

Which patient would the nurse suspect to be at the highest risk for deep chest injury? Patient with a flail chest Patient with a third rib injury Patient with pre-existing pulmonary disease Patient with expired volume of 20 mL/kg

Patient with a flail chest Rationale A patient with a flail chest is at highest risk for a deep chest injury. Patients with a first or second rib injury are at risk for deep chest injury rather than those with a third rib injury. A patient with pulmonary disease is at risk for pneumonia. Patients with expired volume less than 15 mL/kg may have deep chest injury.

Which statement is accurate about a patient with chest trauma? Patients with a lung contusion should be restricted from IV fluids. Patients with severe hypoxemia respond to treatment with humidified oxygen. Patients with rib fractures are primarily treated by surgical stabilization. Patients with a flail chest are stabilized by using positive-pressure ventilation.

Patients with a flail chest are stabilized by using positive-pressure ventilation. Rationale Patients with a flail chest are generally stabilized with positive-pressure ventilation. Patients with severe hypoxemia are managed with positive end-expiratory pressure. Surgical stabilization is performed only in extreme cases of multiple rib fractures that cause flail chest. Patients with a lung contusion should be given IV fluids as prescribed.

Which procedure would help identify a hemothorax in a patient who experienced blunt chest trauma? Palpation Inspection Percussion Auscultation

Percussion Rationale Percussion produces a dull sound over the area of a hemothorax. A hemothorax is characterized by blood in the pleural space and is confirmed by x-ray or a CT scan. A thoracentesis is then performed to remove the blood from the pleural space. A thoracentesis is not performed before radiographic confirmation because of the risks associated with the procedure if a pneumothorax is not present. Palpation is a physical assessment method used to examine the size, tenderness, and location of organs in the body and would not detect blood in the pleural space. Inspection involves observing the appearance of the body and would not detect hemothorax. Auscultation is listening to internal sounds of the body.

A patient who just underwent a central venous access catheter insertion has a deviated trachea and absence of breath sounds on one side. Which complication would the nurse suspect? Flail chest Hemothorax Pulmonary contusion Pneumothorax

Pneumothorax Rationale A deviated trachea and absence of breath sounds on one side are findings in patients with a pneumothorax. Patients with a flail chest may experience paradoxic chest movements. Patients with a hemothorax may have massive blood loss. Patients with pulmonary contusions would have decreased breath sounds or crackles and wheezes.

Which condition is likely to require preparing a patient for chest tube insertion? Flail chest Rib fractures Pneumothorax Pulmonary contusion

Pneumothorax Rationale Chest tubes may be employed in patients with a pneumothorax to facilitate the escape of air, which will allow the lung to reinflate. Humidified oxygen, pain management, and promotion of lung expansion are beneficial interventions in patients with a flail chest. Pain management is the main focus of treatment in patients with rib fractures. Oxygen, IV fluids, and moderate-Fowler position are advocated in patients with pulmonary contusion.

A patient with chronic obstructive pulmonary disease (COPD) reports acute difficulty breathing and right-sided pleuritic pain. Auscultation reveals decreased breath sounds in the right lung field compared with the left lung field. Which condition would the nurse suspect? Flail chest Pneumothorax Pulmonary embolism Tension pneumothorax

Pneumothorax Rationale Patients with COPD may have a spontaneous pneumothorax. Assessment findings frequently include reduced breath sounds on auscultation over the collapsed lung region, hyperresonance on percussion, deviation of the trachea, pleuritic pain, tachypnea, and subcutaneous emphysema. The health care provider or Rapid Response Team must be contacted immediately to evaluate the need for a chest tube to re-expand the lung. Flail chest occurs after trauma. Tension pneumothorax occurs after damage to the pleura allows air to accumulate under positive pressure and is accompanied by cardiovascular collapse. Pulmonary embolism causes dyspnea, but the pain tends to be sharp and stabbing along with a sense of impending doom.

Which nursing intervention is the priority for a patient with chest trauma who is suspected of having a pneumothorax? Managing pain Preparing for a chest tube insertion Maintaining good pulmonary hygiene Continuing respiratory failure assessment

Preparing for a chest tube insertion Rationale When a pneumothorax occurs, the air escapes into the pleural space because of a chest injury. The primary health care provider should immediately place the chest tube, which allows the air to escape and the lung to reinflate. Therefore the nurse should obtain the supplies and set up for a chest tube insertion. Pain management should be performed after preparation for the chest tube. Pulmonary hygiene should be maintained to prevent pulmonary infections. Respiratory failure assessment is continued until the symptoms subside.

The nurse is caring for a patient injured in a car crash. The patient has bruising on the chest, dry cough, and decreased breath sounds. The chest x-ray on admission shows no abnormalities. Which collaborative actions would the nurse expect for this patient? Administer an intercostal nerve block. Administer antibiotics. Perform an immediate needle thoracostomy followed by insertion of a chest tube. Provide oxygen and IV fluids.

Provide oxygen and IV fluids. Rationale The patient injured in a car crash with chest bruising, dry cough, decreased breath sounds, and no chest x-ray abnormalities most likely has a pulmonary contusion, which is managed with oxygen, IV fluids, and placing the patient in a moderate-Fowler position. Severe pain related to rib fracture may be managed with an intercostal nerve block. Antibiotics are indicated for pneumonia. A tension pneumothorax is managed with an immediate needle thoracostomy, followed by the insertion of a chest tube.

The nurse is reviewing the following assessment data for a patient admitted after a motor vehicle crash 3 days ago in which the patient was pinned against the steering wheel. Which condition would the nurse suspect the patient may be developing? Pneumonia Pulmonary edema Pulmonary contusion Pulmonary embolism

Pulmonary contusion Rationale Pulmonary contusion is a common chest injury that most often occurs after a rapid deceleration during a car crash. Pulmonary contusion develops over time rather than immediately. Hemorrhage and edema in the alveoli and interstitial spaces manifest as acute respiratory distress.

Which motion is most often the cause of a pulmonary contusion during a car crash? Slow acceleration Slow deceleration Rapid acceleration Rapid deceleration

Rapid deceleration Rationale Pulmonary contusions, which are potentially lethal, occur most often by rapid deceleration during car crashes. Slow acceleration and deceleration are not associated with pulmonary contusions. Rapid acceleration does not lead to pulmonary contusions.

The plan of care for a patient who sustained rib fractures because of a fall down several stairs includes a goal to maintain clear airways. The nurse teaches the patient how to manage pain and promote lung expansion. Which finding indicates a need to revise the plan of care? Splints chest with movement Uses incentive spirometer hourly Ambulates in hall several times a day Requests pain medication PRN

Splints chest with movement Rationale The nurse would revise the plan of care to provide further education as the patient is splinting the chest with movement. This action decreases the ability to deep breathe and clear secretions, which would lead to atelectasis and pneumonia. Therefore the nurse would provide patient teaching about requesting pain medication. Using the incentive spirometer hourly and ambulating in the hall several times per day promotes lung expansion. The patient requesting pain medication PRN would indicate the patient is managing pain with other methods besides splinting.

Which intervention is reserved for extreme cases of flail chest? Splinting with a tape wrap Surgical stabilization Humidified oxygenation Positive end-expiratory pressure (PEEP) Splinting with a tape wrap Surgical stabilization Humidified oxygenation Positive end-expiratory pressure (PEEP)

Surgical stabilization Rationale Surgical stabilization is used only in extreme cases of flail chest. Splinting is not recommended because it further reduces the patient's ability to exert effectively to breathe and may contribute later to failure to wean from ventilator support. Providing humidified oxygen prevents the upper airway from drying out and may be used in patients with a flail chest, but it is the main intervention for patients with a severe flail chest. Patients with a flail chest and severe hypoxemia and hypercarbia are intubated and mechanically ventilated with PEEP.

Which type of chest trauma produces a hyperresonant sound on percussion of the affected area? Hemothorax Flail chest Pulmonary contusion Tension pneumothorax

Tension pneumothorax Rationale A hyperresonant sound on percussion of the affected area is characteristic of a tension pneumothorax. A hemothorax produces a dull sound on percussion. A flail chest is associated with paradoxical chest wall movement on inspection, but not hyperresonance on percussion. A dull sound on percussion is seen in patients with a pulmonary contusion.

Which complication would the nurse expect in a patient with a torn mainstem bronchus who is rapidly intubated and ventilated with positive pressure? Flail chest Hemothorax Pneumothorax Tension pneumothorax

Tension pneumothorax Rationale A patient with a torn mainstem bronchus may develop a tension pneumothorax rapidly when intubated and ventilated with positive pressure. A flail chest may occur after cardiopulmonary resuscitation. A hemothorax is caused by lung injury and massive blood loss. A pneumothorax may occur from blunt chest trauma and with some degree of hemothorax.

Which condition involves air entering the pleural cavity under pressure? Flail chest Pulmonary contusion Tension pneumothorax Tracheobronchial trauma

Tension pneumothorax Rationale In patients with tension pneumothorax, air enters forcefully into the chest cavity, resulting in increased pressure. This rise in pressure may result in the complete collapse of the lungs. A flail chest occurs because of the fracture of two or more ribs in two or more places. A pulmonary contusion causes hemorrhage and edema between the alveoli. This reduces both lung movement and the area available for gaseous exchange, thus resulting in hypoxemia. Tracheobronchial trauma causes extensive air leakage, leading to subcutaneous emphysema.

Which complication would the nurse suspect if a patient being mechanically ventilated with positive end-expiratory pressure (PEEP) suddenly experiences extreme respiratory distress? Flail chest Hemothorax Pulmonary contusion Tension pneumothorax

Tension pneumothorax Rationale Mechanical ventilation with PEEP may induce a tension pneumothorax in a patient with chest trauma. A flail chest may occur as a complication of cardiopulmonary resuscitation. A hemothorax occurs as a result of blunt chest trauma or penetrating injuries. Distress related to a pulmonary contusion generally develops slowly, over hours to days.

The primary health care provider is examining four patients. Which patient is in need of emergency needle thoracostomy?

Tension pneumothorax Rationale Immediate needle thoracostomy is indicated in Patient D, who has a tension pneumothorax. In this procedure, a large-bore needle is inserted into the second intercostal space in the midclavicular line of the affected side. Then a chest tube is placed into the fourth intercostal space, and the other end is attached to a water-seal drainage system until the lung reinflates. Positive-pressure ventilation and surgical stabilization are indicated for Patient A, who has a flail chest. The primary treatment for treating rib fracture in Patient B is pain management. An intercostal nerve block is used for severe pain management. Patient C, who has a pulmonary contusion, may require mechanical ventilation with positive end-expiratory pressure.

Flow-by ventilation

-beneficial for patients in whom weaning from mechanical ventilation is needed

BiPAP

-provides noninvasive pressure support ventilation by nasal mask or face mask -most often used for pt with sleep apnea

A patient is receiving mechanical ventilation via an endotracheal tube. The patient remains ventilator dependent for 2 weeks after the initial intubation and shows no signs of readiness to wean from the ventilator. Which information would the nurse tell the patient's family about the plan of care? "Your loved one may be ventilator dependent indefinitely." "A tracheostomy will be performed to minimize complications from the tube." "We will insert a nasotracheal tube to make the patient more comfortable." "The health care provider will order bilevel positive airway pressure (BiPAP) to help with weaning."

A tracheostomy will be performed to minimize complications from the tube Rationale Patients who require an artificial airway longer than 10 to 14 days will often need a tracheostomy to help minimize tracheal and vocal cord damage and to continue to remove secretions and provide ventilation and oxygenation. BiPAP is not used to wean patients from ventilators. Nasotracheal tubes carry the same risks as endotracheal tubes and are less comfortable. It is too early to tell whether the patient will be ventilator dependent for a prolonged period of time.

A patient receiving mechanical ventilation and anticoagulant medication after experiencing a pulmonary embolism appears tense and is unable to sleep or rest. Which action should the nurse take? A. Request a prescription for pain medication, and remind the patient to report discomfort. B. Ask the health care provider if conscious sedation may be administered to help the patient rest. C. Explain all interventions to the patient, and provide reassurance that care is appropriate. D. Tell the patient's family that the patient is unstable, and suggest that they remain close by.

Explain all interventions to the patient, and provide reassurance that care is appropriate Rationale Patients who have a pulmonary embolism are usually anxious. The nurse should communicate with the patient to explain interventions and offer reassurance that appropriate measures are being taken. The patient's anxiety is not related to pain. A sedative may be prescribed if other comfort measures are not effective; however, conscious sedation is a specific level of analgesia recommended during uncomfortable or painful procedures or when a mechanically ventilated patient is unable to be oxygenated adequately. Family presence may provide comfort; however, telling the patient's family that the patient is unstable will increase the level of anxiety for everyone involved.

A patient is receiving mechanical ventilation after developing acute respiratory distress syndrome (ARDS) from aspiration pneumonia. The patient's spouse asks the nurse how long it will take the patient to recover. Which response would the nurse provide? A. "Patients eventually recover but require medications indefinitely." B. "Recovery time depends on the severity and progression of symptoms." C. "With appropriate medications and treatments, most patients recover fully." D. "Patients with ARDS have permanent lung damage and require long-term care."

Recovery time depends on the severity and progression of symptoms Rationale The most accurate answer is to tell the family member that the severity and progression of symptoms can indicate recovery chances and length of time to recovery. Not all patients will eventually recover or need medication indefinitely, nor do all patients recover fully, even with aggressive medical and nursing treatment. Permanent lung damage is not always the result of ARDS. Permanent damage is typically seen in those who progress to stage 4 disease.

A patient who is being mechanically ventilated shows increased respiratory distress, including intercostal retractions, anxiety, and restlessness, with an oxygen saturation of 86%. Which action would the nurse perform first? A. Increase the oxygen flow rate and fraction of inspired oxygen (Fio 2) levels. B. Remove the ventilator, and provide manual ventilation. C. Suction the patient via the endotracheal tube. D. Notify the health care provider, and request an order for blood gas evaluation.

Remove the ventilator, and provide manual ventilation Rationale Patients who develop respiratory distress while being mechanically ventilated should be manually ventilated to allow quick assessment of whether the problem is with the ventilator or the patient. Increasing oxygen flow rate and Fio 2 levels, obtaining an order for blood gases, or suctioning may be indicated based on the assessment while manually ventilating the patient.