Chapter 34 Care of Critically Ill patient's with Respiratory Problems

The nurse is assessing a pt who was extubated several hours ago. Which pt finding warrants notification of the Rapid Response team?

-Inability to expectorate secretions

Ventilatory failure is the result of what processes?

-Defect the respiratory control center of the brain. -Physical problem of the lungs. -Poor function of the diaphragm -Physical problem of the chest wall

The nursing student is assisting in the care of a critically ill patient on a ventilator. Which action by the student nurse requires intervention by the supervising nurse?

-Deflates the cuff on the ET tube to check placement

-Bronchial asthma -Chronic bronchitis -Pulmonary emphysema

Combination of ventilatory & oxygenation failure

-Pneumonia -Smoke inhalation -Carbon monoxide poisoning

Oxygenation Failure

The nurse's young neighbor who smokes is going on an overseas flight. The neighbor knows he's at risk for DVT & PE, & asks the nurse for advice. What does the nurse suggest?

-Drink water; get up every hour for @ least 5 minutes during the flight.

What does the nurse monitor for in a patient with a PE?

-Cyanosis -Rapid HR -Dyspnea -Crackles in the lung fields

Which pts on mechanical ventilators are at high risk for barotrauma?

-Pt with ARDS -Pt with underlying chronic airflow limitation -Pt on PEEP

Which are extrapulmonary causes of ventilatory failure?

-Stroke -Use of opioid analgesics -Morbid obesity

Which finding might delay weaning a patient from mechanical ventilation support?

Arterial Po2= 70 mm Hg on a 40% Fio2.

A patient in the ED required emergency intubation for status asthmaticus. Immediately after the insertion of the ET tube, how does the nurse and/or physician verify correct placement?

Auscultate for bilateral breath sounds

A pt in a motor vehicle accident was unrestrained & appears to have hit the front dashboard. The pt has severe respiratory distress, inspiratory stridor, & extensive subcutaneous emphysema. The ED physician identifies tracheobronchial trauma. Which procedure does the nurse immediately prepare for?

Cricothyroidotomy

A pt in respiratory failure is diagnosed with a flail chest. After the pt is intubated, which treatment does the nurse expect to be implemented?

PEEP

A patient is following up on a post op complication of PE. The patient must have blood drawn to determine the therapeutic range for Coumadin. Which lab test determines this therapeutic range?

PT & INR

Hollow tube extending from naso-oral cavity to just above the carina

Shaft

The patient who's having a _______________ attack is at risk for combined ventilatory & oxygenation failure.

asthma

The nurse is assessing a patient with a hemothorax. When the nurse performs percussion of the chest on the affected side, what type of sound if expected?

-Dull

A patient with a PE is receiving anticoagulant therapy. Which assessment related to the therapy does the nurse perform?

-Examine skin every 2 hours for evidence of bleeding.

The nurse is assisting with an emergency intubation for a pt in severe respiratory distress. Although the physician is experienced, the procedure is difficult b/c the patient has severe kyphosis. At what point does the nurse intervene?

-First intubation attempt lasts longer than 30 seconds.

A pt with which condition is a potential candidate for autotransfusion, should the need arise?

-Hemothorax

Which assessment finding is considered an early sign of ARDS?

-Intercostal & suprasternal retractions

The nurse hears in shift report that a pt has been agitated & pulling at the ET. Restraints have recently been ordered & placed, but the pt continues to move his head & chew at the tube. What does the nurse do to ensure proper placement of the ET tube?

-Mark the tube where it touches the pt's teeth.

A pt is admitted after a near-drowning & develops ARDS which is confirmed by the physician. The nurse prepares equipment for which treatment?

-Mechanical ventilation & endotracheal tube

The nurse is caring for a patient with acute hypoxemia. Which nursing interventions are best for the care of this patient?

-Minimal self-care -Upright position -Oxygen therapy -Prescribed metered dose inhalers

The high-pressure alarm of a pt's mechanical ventilator goes off. What are the potential causes for this occurrence?

-Mucus plus -Patient's fighting the ventilator -Bronchospasm -Patient is coughing

The nurse is performing a check of the ventilator equipment. What's included during the equipment check?

-Note the prescribed & actual settings.

The nurse is caring for several patients at risk for DVT & PE. Which condition causes the patient to be the most likely candidate for placement of a vena cava filter?

-Recurrent bleeding while receiving anticoagulants

Device to provide a seal between the trachea & tube

Cuff

The nurse is caring for several post op patients at risk for developing PE. Which interventions does the nurse use to help prevent the development of PE in these patients?

-Start passive & active range-of-motion exercises for the extremities. -Ambulate postop. patients soon after surgery. -Use anti-embolism devices post op. -Administer drugs to prevent episodes of Valsalva maneuver.

Which conditions define respiratory failure?

-Ventilatory failure -Oxygenation failure -Combination of ventilatory & oxygenation failure

In _______________ _______________, ventilation-perfusion (V/Q) mismatch is found in conditions where perfusion is normal & ventilation is also inadequate.

ventilatory failure

A patient with a PE asks for an explanation of heparin therapy. What's the nurse's best response?

"It increases the time it takes for blood to clot, therefore preventing further clotting & improving blood flow"

Acute respiratory failure is classified by which critical values of Paco2?

-52 mm Hg -<60 mm Hg ->50 mm Hg with a pH value of <7.3

The nurse notices that a patient has a gradual increase in peak inspiratory pressure over the last several days. What's the best nursing intervention for this patient?

-Assess for a reason such as ARDS or pneumonia.

Device to allow attachment of ET tube to ventilation source

Adapter

A pt is admitted to the trauma unit following a front-end motor vehicle collision. The patient is currently asymptomatic, but the physician advises the nurse that the pt has a high risk for pulmonary contusion. What does the nurse carefully monitor for?

Decreased breath sounds

Which clinical manifestations can occur from cardiac problems due to mechanical ventilation?

Decreased cardiac output Fluid retention

What's the most common site of origin for a clot to occur, causing a PE?

Deep veins of the legs & pelvis

A 19 year old patient was seen in the ED after a motorcycle accident for multiple rib fractures that resulted in free-floating ribs, paradoxical breathing & inadequate oxygenation. What's this condition called?

Flail chest

What's the cardiac problem that can occur from mechanical ventilation?

Hypotension

A pt on a ventilator is biting & chewing at the ET tube. Which nursing intervention is used for ET management?

Insert an oral airway

A client with severe respiratory insufficiency becomes short of breath during activities of daily living. Which nursing intervention is best? a. Call the Rapid Response Team. b. Decrease involvement in care until the episode is past. c. Cluster morning activities to provide long rest periods. d. Space out interventions to provide for periods of rest.

NS: B Clients with shortness of breath and decreased oxygen saturation must be monitored closely. Minimal involvement in activities is required if the client is severely short of breath. The nurse should continue to assess the client and can increase involvement in activities if shortness of breath subsides. The Rapid Response Team is not required. Clustering or spacing of activities does nothing to decrease the client's involvement, which is the cause of shortness of breath.

A patient with ARDS is currently in the phase 1 management stage. What's the focus of the nursing assessment?

Note early changes in dyspnea & tachypnea.

Access site for inserting air into the cuff

Pilot balloon

What causes the potential cardiac problems that can result from mechanical ventilation?

Positive pressure increases the chest

A pt sustained a chest injury resulting from a motor vehicle accident. The pt is asymptomatic at first, but slowly develops decreased breath sounds, crackles, wheezing, & blood in the sputum. The mechanism of injury & physical findings are consistent with which condition?

Pulmonary Congestion

The nurse is caring for a pt at risk for pulmonary contusion. Why's this a potentially lethal chest injury?

Respiratory failure develops over time.

An _____________ _______________ embolus carries a high mortality rate & occurs as a rare complication of childbirth, abortion, or amniocentesis.

amniotic fluid

Any substance can cause an embolism, but ______________ ___________ are the most common cause.

blood clots

In ______________ _______________ there is V/Q mismatch in which air movement & oxygen intake are normal & lung perfusion is decreased.

oxygenation failure

A pt is intubated & has mechanical ventilation with positive end-expiratory pressure (PEEP). B/c this pt is at risk for a tension pneumothorax, what's the nurse's priority action?

-Assess lung sounds every 30 to 60 minutes

The nurse is caring for a pt who has just been extubated. What interventions does the nurse use in caring for this pt?

-Assess the ventilatory pattern for manifestations of respiratory distress. -Instruct the pt to take deep breaths every half hour -Encourage use of an incentive spirometer every 2 hours -Advise the pt to limit speaking right after extubation.

The nurse is caring for a pt on a mechanical ventilation. What does the nurse monitor to assess for the most likely cardiac problem associated with this therapy?

-Check BP

The nurse is caring for a patient on a mechanical ventilator. During the shift, the nurse hears the patient talking to himself. What does the nurse do next?

-Check the inflation of the pilot balloon.

A pt reports pain with inspiration after falling off a skateboard. The physician makes the diagnosis of rib fracture. The nurse prepares to do patient teaching for which treatment?

-Coughing & deep breathing

The high-pressure alarm of a patient's mechanical ventilator goes off. What are potential causes for this occurrence?

-Cuff leak in the endotracheal or tracheostomy tube -Pt has stopped bleeding -Leak in the circuit

A patient with a massive PE has hypotension & shock, & is receiving IV crystalloids. However, the patient's cardiac output is not improving. The nurse anticipates an order for which drug?

-Dobutamine (Dobutrex)

The nurse is performing patient teaching for a patient who will be taking anticoagulants at home. What does the nurse include in the instructions?

-Don't take aspirin or any aspirin-containing products. -Don't participate in activities that will cause bumps, scratches, or scrapes -Eat warm, cool, or cold foods to avoid burning your mouth. -If you must blow your nose, do so gently without blocking either nasal passage.

A pt has a history of COPD & had to be intubated for respiratory failure. The pt is currently on a mechanical ventilator. The nurse obtains an order for which type of dietary therapy for this pt?

-High-fat nutritional supplement

On arrival to the ED, the patient develops extreme respiratory distress & the physician identifies a tension pneumothorax. The nurse prepares to assist with which urgent procedure?

-Insertion of a large-bore needle into the intercostal space on the affected side.

What are the characteristics of a mechanical ventilator that is pressure-cycled?

-It's a positive pressure ventilator. -It pushes air into the lungs until a preset airway pressure is reached. -Tidal volumes & inspiratory times are varied.

Which conditions are related to acute respiratory distress syndrome (ARDS)?

-Lung fluid increases -A systemic inflammatory response occurs -Lung volume is decreased -Hypoxemia results

The nurse is caring for a patient on a mechanical ventilator. Which assessments for the nurse perform for this pt?

-Observe the pt's mouth around the tube for pressure ulcers. -Auscultate the lungs for crackles, wheezes, equal breath sounds, & decreased or absent breath sounds. -Assess the placement of the ET. -Check to be sure alarms are set -Observe the patient's need for tracheal, oral, or nasal suctioning every 2 hours.

A pt is being treated with heparin therapy for a PE. The patient has the potential for bleeding with the administration of heparin. What does the nurse monitor in relation to the heparin therapy?

-PTT values for greater than 2.5 times the control &/or the pt for bleeding.

Upon diagnosis of a PE, the nurse expects to perform which therapeutic intervention for the patient?

-Parenteral anticoagulant therapy

The nursing student is assisting in the care of a pt on a mechanical ventilator. Which action by the student contributes to the prevention of ventilator-assisted pneumonia?

-Performs oral care every 2 hours

The nurse hears in report that a pt with ARDS has been intubated for 6 days & has progressive hypoxemia that responds poorly to high levels of oxygen. This pt is in which phase of ARDS case management?

-Phase 3

A pt has been successfully intubated by the physician, & the nurse & respiratory therapist are securing the tube in place. What does the nurse include in the documentation regarding the intubation procedure?

-Presence of bilateral & equal breath sounds -Level of the tube -Changes in vital signs during the procedure -Presence (or absence) of dysrhythmias -Placement verification by end-tidal carbon dioxide levels

A post op patient reports sudden onset of SOB & pleuritic chest pain. Assessment findings include diaphoresis, hypotension, crackles in the left lower lobe, & pulse ox of 85%. What does the nurse suspect this pt has?

-Pulmonary embolism

The nurse is caring for a patient with a post-op complication of PE. The pt has been receiving treatment for several days. Which factors are indications of adequate perfusion in the patient?

-Pulse ox of 95% -Absence of pallor or cyanosis -Mental status at pt's baseline

The physician orders heparin therapy for a patient with a relatively small PE. The patient states, "I didn't tell the doctor my complete medical history." Which condition may affect the physician's decision to immediately start heparin therapy?

-Recent cerebral hemorrhage

A patient demonstrates chest pain, dyspnea, dry cough, & change in level of consciousness. The nurse suspects PE & notifies the HCP who orders an arterial blood gas (ABG). In the early stage of a PE, what would ABG results probably indicate?

-Respiratory alkalosis

A pt in the critical care unit requires an emergency ET intubation. The nurse immediately obtains & prepares which supplies to perform this procedure?

-Resuscitation Ambu Bag -Source for 100% oxygen -Suction equipment -Insertion equipment -Oral airway

The nurse suspects a pt has a PE & notifies the physician who orders an arterial blood gas. The physician is en route to the facility. The nurse anticipates & prepares the patient for which additional diagnostic test?

-Spiral CT scan

The nurse is caring for several post op patients with high risk for a PE. All of these patients have pre-existing chronic respiratory problems. What's a unique assessment finding for a clot in the lung?

-Sudden dry cough

A patient recently received anticoagulant therapy for complications of PE after knee surgery. The patient is now in a rehab facility & is receiving warfarin (Coumadin). What's the nursing responsibility related to Coumadin?

-Teaching the patient about foods high in vitamin K?

The nurse is assessing a patient who sustained significant chest trauma during a motor vehicle accident. What significant assessment finding suggests tension pneumothorax?

-Tracheal deviation to the unaffected side

What are the risk factors for pulmonary embolism (PE) & DVT?

-Trauma -HF -Cancer (particularly lung or prostate)

The nurse is caring for several patient's on the medical-surgical unit who are experiencing acute respiratory problems. Which conditions may eventually require a patient to be intubated?

-Trouble maintaining a patent airway because of mucosal swelling. -Copious secretions & lacking muscular strength to cough. -Increasing fatigue b/c of the work of breathing

An older adult patient on anticoagulation therapy for a PE is somewhat confused & requires assistance with ADLs. Which instruction specific to this therapy does the nurse give to the UAP?

-Use a lift sheet when moving or turning the patient in bed.

After receiving IV heparin anticoagulant therapy, patients are generally not discharged from the hospital without a prescription & instructions for which drug?

-Warfarin (Coumadin)

The nurse is reviewing lab results for a patient with a new onset of PE. What's the INR therapeutic range?

2.0 to 3.0 times the normal value

Which pt has the greatest risk for developing ARDS?

74 year old who aspirates a tube feeding.

It is determined that a client has a large pulmonary embolism (PE). Fibrinolytic therapy is initiated. What is the nurse's priority action? a. Monitor the client's oxygenation. b. Teach the client about potential side effects. c. Monitor the IV insertion site. d. Monitor for bleeding.

ANS: A Airway and breathing are the top priority. The nurse would also need to monitor for bleeding when administering fibrinolytic therapy, and would monitor the IV site as well. Teaching the client is also a need, however. Oxygenation is the highest priority.

The nurse is caring for a client who is intubated with an endotracheal tube and on a mechanical ventilator. The client is able to make sounds. What is the nurse's first action? a. Check cuff inflation on the endotracheal tube. b. Listen carefully to the client. c. Call the health care provider. d. Auscultate the lungs.

ANS: A If the client has the cuff on the endotracheal tube inflated, the cuff should prevent air from going around the cuff and through the vocal cords. If the client can talk with the cuff inflated, the cuff probably has a leak, causing it to become deflated and allowing air to pass through. The risk is that the client will not receive the prescribed tidal volume.

The nurse is caring for a client who is receiving mechanical ventilation accompanied by positive end-expiratory pressure (PEEP). What assessment findings require immediate intervention? a. Blood pressure drop from 110/90 mm Hg to 80/50 mm/Hg b. Pulse oximetry value of 96% c. Arterial blood gas (ABG): pH, 7.40; PaO2, 80 mm Hg; PaCO2, 45 mm Hg; HCO3-, 26 mEq/L d. Urinary output of 30 mL/hr

ANS: A Increased intrathoracic pressure can inhibit blood return to the heart and cause decreased cardiac output. This manifests with a drop in blood pressure. The pulse oximetry reading, ABGs, and urinary output are all normal.

A client admitted with respiratory difficulty and decreased oxygen saturation keeps pulling off the oxygen mask. What action does the nurse take? a. Stays with the client and replaces the oxygen mask b. Asks the client's spouse to hold the oxygen mask in place c. Restrains the client per facility policy d. Contacts the health care provider and requests sedation

ANS: A Restlessness and confusion are clinical manifestations of hypoxemia. It is important that the nurse stay with the client, ensure that the oxygen is maintained, and attempt to calm the client. Because of the client's restlessness, the nurse cannot delegate care to the spouse. Requesting a sedative might adversely affect the client's respiratory status further. Restraining the client could increase restlessness and increase oxygen demand.

The nurse is caring for a postoperative client who suddenly reports difficulty breathing and sharp chest pain. After notifying the Rapid Response Team, what is the nurse's priority action? a. Elevate the head of the bed and apply oxygen. b. Listen to the client's lung sounds. c. Pull the call bell out of the wall socket. d. Assess the client's pulse oximetry.

ANS: A The client's immediate need is to have oxygen applied. The nurse should then assess the client's pulse oximetry.

What is the best way for the nurse to communicate with a client who is intubated and is receiving mechanical ventilation? a. Ask the client to point to words on a board. b. Ask the client to blink for "yes" and "no." c. Have the client mouth words slowly. d. Teach the client some simple sign language.

ANS: A The nurse should have the client point to words on a board to communicate needs. The endotracheal tube is positioned and placement is maintained with tape or some other type of appliance. Asking the client to move his or her mouth and lips could result in possible extubation. Communication is limited and could be misunderstood with blinking. Teaching the client sign language, even simple, would be an involved and unrealistic goal.

A client admitted for difficulty breathing becomes worse. Which assessment findings indicate that the client has developed acute respiratory distress syndrome (ARDS)? (Select all that apply.) a. Oxygen administered at 100%, PaO2 60 b. Increased dyspnea c. Anxiety d. Chest pain e. Pitting pedal edema f. Clubbing of fingertips

ANS: A, B, C A client who is developing ARDS presents with a decrease in oxygen despite an increase in the fraction of inspired oxygen. Increased dyspnea goes along with the increased hypoxemia, as does anxiety. Chest pain is not specific to ARDS; although chest pain can occur with ARDS, it occurs with many other conditions as well. Pitting edema would not be an assessment factor that confirms ARDS. Clubbing occurs in chronic, not acute, respiratory conditions. pg 671

The nurse is caring for a client on a ventilator when the high-pressure alarm sounds. What actions are most appropriate? (Select all that apply.) a. Assess the tubing for kinks. b. Assess whether the tubing has become disconnected. c. Determine the need for suctioning. d. Call the health care provider. e. Call the Rapid Response Team. f. Auscultate the client's lungs.

ANS: A, C, F Reasons for a high-pressure alarm include water or a kink impeding airflow or mucus in the airway. The nurse first should assess the client and determine whether he or she needs to be suctioned; then the nurse should auscultate the lungs. The nurse also should assess the tubing for kinks. The high-pressure alarm sounding would not be a reason to call the health care provider or the Rapid Response Team. If the tubing became disconnected, the low-pressure alarm would sound.

The nurse is caring for a client with a high risk for pulmonary embolism (PE). Which prevention measures does the nurse add to the client's care plan? (Select all that apply.) a. Use antiembolism stockings. b. Massage calf muscles per client request. c. Maintain supine position with the legs flat. d. Turn every 2 hours if client is in bed. e. Refrain from active range-of-motion exercises.

ANS: A, D Both antiembolism stockings (or sequential pressure devices) and a turning schedule can help prevent venous thromboembolism, which can lead to PE. Massaging the calves is discouraged because this can cause a clot to break loose and travel to the lungs. Legs should be elevated when in bed, and the client should perform active range of motion (ROM) if able. If the client is unable to perform active ROM, the nurse should provide passive ROM. pg 663

The nurse is caring for a client with a ventilation/perfusion mismatch who is receiving mechanical ventilation. Which intervention is a priority for this client? a. Administering antibiotics every 6 hours b. Positioning the client with the "good lung dependent" c. Making sure that the pilot balloon line on the endotracheal tube is deflated d. Ensuring that the client is able to speak clearly

ANS: B Clients who are being mechanically ventilated are experiencing a problem in that their normal ventilation is not adequate. The recommended position for clients who have one lung more affected by a problem than the other lung is to place the "good lung down," keeping the healthier lung dependent to the less healthy lung. Such positioning allows gravity to keep more blood in the lower lung (healthier lung) and better ventilation in the upper lung, thus helping a ventilation/perfusion mismatch. Antibiotics are not prescribed for this disorder. The pilot balloon line should be inflated to ensure that the cuff is inflated, keeping the endotracheal tube in place and directing ventilated air into the lungs. The client with an endotracheal tube that is nonfenestrated, with the cuff inflated, will not be able to speak. Communication is addressed in other ways.

A client is admitted to the emergency department several hours after a motor vehicle crash. The car's driver-side airbag was activated during the accident. Which assessment requires the nurse's immediate intervention? a. Disorientation b. Hemoptysis c. Pulse oximetry reading of 94% d. Chest pain with movement

ANS: B The nurse should be concerned about possible pulmonary contusion. Interstitial hemorrhage accompanies pulmonary contusion. Bleeding may not be evident at the initial injury, but the client develops hemoptysis and decreased breath sounds up to several hours after injury as bleeding into the alveoli or airways occurs. The pulse oximetry reading is within normal limits and chest pain is expected with movement after chest trauma. Disorientation needs to be investigated, but does not take priority over a breathing problem.

The pilot balloon on the endotracheal tube of a client being mechanically ventilated is deflated. What is the nurse's priority action? a. Nothing; this is required during ventilation. b. Inflate the cuff using minimal leak technique. c. Call the Rapid Response Team. d. Increase the tidal volume.

ANS: B The pilot balloon indicates whether the endotracheal tube cuff is inflated or deflated. A deflated balloon means that the cuff is also deflated and a seal is no longer present around the tube to prevent air from escaping. Thus, some of the air being moved into the client's airway by the ventilator is escaping through the client's trachea before it reaches the lower airways and alveoli. The nurse should inflate the cuff. Calling the Rapid Response Team is not necessary, and increasing tidal volume will not improve oxygenation if the cuff is leaking.

The nurse is caring for a client with a pulmonary embolus who also has right-sided heart failure. Which symptom will the nurse need to intervene for immediately? a. Respiratory rate of 28 breaths/min b. Urinary output of 10 mL/hr c. Heart rate of 100 beats/min d. Dry cough

ANS: B Urinary output is very low; this could indicate that the client has decreased cardiac output. The nurse will need to intervene and notify the health care provider. A respiratory rate that is slightly elevated is expected in this condition. Likewise, a heart rate that is a little higher is expected in this situation. A dry cough is also commonly found with pulmonary embolus.

Which clients are at highest risk for pulmonary embolism (PE)? (Select all that apply) a. Middle-aged client awaiting surgery b. Older adult with a 20-pack-year history of smoking c. Client who has been on bedrest for 3 weeks d. Obese client who has elevated platelets e. Middle-aged client with diabetes mellitus type 1 f. Older adult who has just had abdominal surgery

ANS: B, C, D, F Older adults, especially those with chronic lung problems, are at higher risk for pulmonary embolism. Prolonged bedrest is also a risk factor, as are abdominal surgery and smoking. Because platelets are involved in the clotting process, elevated platelets may contribute to increased clotting. Diabetes and waiting for surgery are not known risk factors. pg 663

Which symptoms in a client assist the nurse in confirming the diagnosis of pulmonary embolus (PE)? (Select all that apply.) a. Wheezes throughout lung fields b. Hemoptysis c. Sharp chest pain d. Flattened neck veins e. Hypotension f. Pitting edema

ANS: B, C, E Hemoptysis, sharp chest pain, and hypotension all may be caused by pulmonary embolism and the pulmonary hypertension that results. Rather than wheezes, crackles usually occur along with a dry cough. pg 664

The pressure reading during inspiration on the ventilator of a client receiving mechanical ventilation is fluctuating widely. What is the nurse's first action? a. Determine whether an air leak is present in the client's endotracheal tube cuff. b. Have the respiratory therapist check the pressure settings. c. Assess the client's oxygenation. d. Manually ventilate the client with a resuscitation bag.

ANS: C A widely fluctuating pressure reading is one indication of inadequate airflow and oxygenation. The nurse's priority is to check the client's oxygenation status. If oxygenation is inadequate, the nurse would assess for a cause while manually ventilating the client and calling for assistance.

The nurse assesses a client admitted for chest trauma who reports dyspnea. The nurse finds tracheal deviation and a pulse oximetry reading of 86%. What is the nurse's priority intervention? a. Notify the health care provider and document the symptoms. b. Intubate the client and prepare for mechanical ventilation. c. Administer oxygen and prepare for chest tube insertion. d. Administer an intermittent positive-pressure breathing treatment.

ANS: C Blunt chest trauma can cause an air leak into the thoracic cavity, collapsing the lung on the side with the air leak (pneumothorax). More air enters the pleural space with each breath, increasing intrathoracic pressure on the affected side, moving the trachea to the unaffected side, and leading to decreased cardiac output. This condition (tension pneumothorax) is life threatening without intervention. The client will need oxygen administration right away and a chest tube inserted

The nurse is caring for a client with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation and positive end-expiratory pressure (PEEP). The alarm sounds, indicating decreased pressure in the system. What is the nurse's best action? a. Change the client's position. b. Suction the client. c. Assess lung sounds. d. Turn off the pressure alarm.

ANS: C One of the biggest risks in the client with ARDS on mechanical ventilation with PEEP is tension pneumothorax. The nurse needs to assess lung sounds hourly. The alarms on a ventilator should never be turned off. If the client needed to be suctioned, the high-pressure alarm would sound. Changing the client's position would not change the pressure needed to administer a breath.

A client states, "At night, I usually need to sleep propped up on two pillows in the chair, but now it seems I need three pillows." What is the nurse's best response? a. "You should try to rest more during the day." b. "You should try to lie flat for short periods of time." c. "You need to stay in the hospital for further evaluation." d. "You can take medication at night so you can sleep."

ANS: C Orthopnea is the sensation of dyspnea or breathlessness in the supine position. Clients feel that they cannot catch their breath in the supine position and must rest or sleep in a semi-sitting position by placing pillows behind their backs or by using a reclining chair. The degree of breathlessness can be measured roughly by the number of pillows needed to make the client less dyspneic (e.g., one-pillow orthopnea, two-pillow orthopnea). With a client who has chronic respiratory problems, a minor increase in dyspnea may indicate a severe respiratory problem. Respiratory failure is a high risk. This client needs to stay in the hospital to be evaluated more completely. The client should not be instructed to try to lie flat, or to take a sleeping pill.

The nurse assesses a client who has a hemothorax and a chest tube inserted on the right side. What finding requires immediate attention? a. Pain at the chest tube insertion site b. Fluctuation in the water seal chamber with breathing c. Puffiness of the skin around the chest tube insertion site and a crackling feeling d. Dullness to percussion on the affected side

ANS: C Puffiness of the skin around the chest tube and a crackling feeling indicate subcutaneous emphysema, or air leaking into the tissue around the insertion site. This must be addressed immediately. A hemothorax involves bleeding into the thoracic cavity and decreased lung inflation on the affected side, resulting in duller and less resonant percussion notes. Pain at the insertion site, fluctuation in the water seal, and dullness to percussion are all expected.

The nurse auscultates the lungs of a client on mechanical ventilation and hears vesicular breath sounds throughout the right side but decreased sounds on the left side of the chest. What is the nurse's best action? a. Turn the client to the right side. b. Elevate the head of the bed. c. Assess placement of the endotracheal (ET) tube. d. Suction the client.

ANS: C The endotracheal tube is more likely to slip into the right mainstem bronchus, leading to the breath sounds described. The nurse should assess placement of the ET tube by assessing where the markings are, making sure it is taped, and confirming equal breath sounds bilaterally. If it is believed that the tube has slipped into the right mainstem bronchus, the health care provider should order a chest x-ray and reposition the tube.

The nurse is caring for several clients on the respiratory floor. Which client does the nurse assess most carefully for the development of acute respiratory distress syndrome (ARDS)? a. Older adult with COPD b. Middle-aged client receiving a blood transfusion c. Older adult who has aspirated his tube feeding d. Young adult with a broken leg from a motorcycle accident

ANS: C The older adult who has aspirated a tube feeding is at high risk and should be assessed closely for the possibility of ARDS. A client with COPD and a middle-aged client with no other risk factors are not at as high a risk for ARDS. The client who has a broken leg from an accident is not at high risk.

The nurse assesses a client who suffered chest trauma and finds that the left chest sucks in during inhalation and out during exhalation. The client's oxygen saturation has dropped from 94% to 86%. What is the priority action by the nurse? a. Encourage the client to take deep, controlled breaths. b. Document findings and continue to monitor the client. c. Notify the health care provider and prepare for intubation. d. Stabilize the chest wall with rib binders.

ANS: C This client has a flail chest characterized by paradoxical chest wall motion. With the oxygen saturation dropping, the client is at high risk for respiratory failure and needs to be intubated. Deep-breathing exercises are not enough at this point. Rib binders are not used anymore because they limit chest wall expansion and were used only for simple rib fractures.

The nurse is prioritizing care for a client on a ventilator. What are essential nursing interventions for this client? (Select all that apply.) a. Change the settings in accordance with provider orders. b. Modify the settings for weaning the client. c. Assess the reasons for alarms. d. Compare the ventilator settings with ordered settings. e. Assess the water level in the humidifier. f. Change the ventilator tubing according to hospital policy.

ANS: C, D, E The nurse should assess the client when an alarm sounds and should intervene accordingly. The nurse should also check the settings to make sure they are correct and should evaluate the water level to make sure the humidifier does not go dry. The nurse would not be responsible for changing ventilator settings, weaning the client, or changing the ventilator tubing.

The nurse is caring for a client who is taken off a ventilator and placed on continuous positive airway pressure (CPAP). What intervention is most appropriate for this client? a. Administering antianxiety medications PRN b. Administering a medication to help the client sleep c. Telling the client to relax and let the ventilator do the work d. Making sure the client is breathing spontaneously

ANS: D A requirement for using CPAP is that the client will be able to breathe spontaneously. Antianxiety and sleep medications should not be administered to the client during weaning. Telling the client to relax may be helpful in some cases but does not take priority over ensuring the client's ability to breathe spontaneously.

A client with a large pulmonary embolism is receiving alteplase (Activase). The nurse notes frank red blood in the Foley catheter drainage bag. What is the nurse's first action? a. Irrigate the Foley. b. Administer an antibiotic. c. Clamp the Foley. d. Notify the health care provider.

ANS: D Alteplase is a fibrinolytic agent that dissolves formed clots. The drug has an impact on clots outside the pulmonary embolism, and the client is at great risk for hemorrhage and shock. The nurse should realize the potential for a severe problem and should call the health care provider immediately for orders. The other actions would not be appropriate first actions in this situation.

The nurse notes that each time the mechanical ventilator delivers a breath to a client with acute respiratory distress syndrome (ARDS), the peak inspiratory pressure alarm sounds. What is the nurse's best intervention? a. Suction the client. b. Perform chest physiotherapy. c. Administer an inhaler. d. Assess the airway.

ANS: D An increase in peak inspiratory pressure (PIP) in the ARDS client is indicative of decreased lung compliance, making it more difficult to ventilate diseased lungs. The nurse first should assess the airway to make sure no sputum is present in the airway and that no kinks are noted in the tubing. The nurse is not able to make changes in the ventilator settings, so an order is needed to increase inspiratory pressure to oxygenate the client. Suctioning or performing chest physical therapy (PT) will not help the client's lung compliance; however, if mucus is impeding the airway, these interventions would be necessary and would be noticed when the airway is assessed. Administering a bronchodilator may help the client; however, an inhaler could not be used by a client on a ventilator.

The client receiving mechanical ventilation has become more restless over the course of the shift. Which is the nurse's first action? a. Sedate the client. b. Call the health care provider. c. Assess the client for pain. d. Assess the client's oxygenation.

ANS: D Increasing restlessness in a client being mechanically ventilated may mean that the client is not receiving sufficient oxygen. It can also be a manifestation of pain. When in doubt, determining the adequacy of ventilation has the highest priority. The nurse would not sedate the client until the cause of the restlessness has been addressed. The nurse would call the provider if the cause could not be determined and addressed, or if the client's status deteriorated.

The nurse is caring for a client receiving heparin and warfarin therapy for a pulmonary embolus. The client's international normalized ratio (INR) is 2.0. What is the nurse's best action? a. Increase the heparin dose. b. Increase the warfarin dose. c. Continue the current therapy. d. Discontinue the heparin.

ANS: D The client who is being treated for pulmonary embolism usually continues on heparin and warfarin until the INR reaches a therapeutic level between 2 and 3. Heparin can then be discontinued because warfarin is therapeutic.

The nurse is caring for a client who has been intubated and placed on a ventilator for treatment of acute respiratory distress syndrome (ARDS). Aside from assessing oxygenation, what is the nurse's priority action? a. Assess hemoglobin. b. Administer ferrous sulfate. c. Assess muscle strength. d. Consult with the registered dietitian.

ANS: D The client who is intubated needs nutrition delivered via enteral tube feeding. If nutrition is ignored, the client's respiratory status can deteriorate, because respiratory muscle function can deteriorate.

Which assessment finding of a client requires the nurse's immediate action? a. Being intubated for 4 days b. Uneven breath sounds c. Wheezing on auscultation d. Having the endotracheal (ET) tube taped to the lower jaw

ANS: D The endotracheal tube can be taped to the upper lip but should never be taped to the lower jaw because the lower jaw moves too much. The other clients need to be assessed by the nurse, but the one with the ET tube taped to the jaw requires immediate action.

A client with dyspnea is becoming very anxious. An arterial blood gas (ABG) shows a PaO2 of 93 mm Hg. How does the nurse best intervene? a. Increase the oxygen. b. Administer an antianxiety medication. c. Administer a bronchodilator. d. Assist with relaxation techniques.

ANS: D The nurse should assess the client's oxygenation; however, this client's arterial blood gas documents that the client's hypoxia has resolved. At this time it is not necessary to increase the oxygen or administer a bronchodilator; both of these interventions would be appropriate if the client were hypoxic. The client with respiratory problems should not take an antianxiety medication as a first-line intervention, because this may decrease the respiratory rate and/or alertness. The best intervention at this time is to assist with relaxation techniques.

The nurse is assessing arterial blood gases (ABGs). The client with which ABG reading requires the nurse's immediate attention? a. pH, 7.32; PaCO2, 55 mm Hg; PaO2, 70 mm Hg b. pH, 7.45; PaCO2, 42 mm Hg; PaO2, 70 mm Hg c. pH, 7.48; PaCO2, 38 mm Hg; PaO2, 60 mm Hg d. pH, 7.55; PaCO2, 32 mm Hg; PaO2, 50 mm Hg

ANS: D This client has the most severe hypoxia and respiratory alkalosis, indicated by low partial pressure of arterial carbon dioxide (PaCO2) values on ABG analysis.

A client is admitted owing to difficulty breathing. The nurse assesses the client's color, lung sounds, and pulse oximetry reading. The pulse oximetry is 90%. What is the nurse's next action? a. Give an intermittent positive-pressure breathing treatment. b. Administer a rescue inhaler. c. Call for a chest x-ray. d. Assess an arterial blood gas.

ANS: D When clients with respiratory problems are assessed, an arterial blood gas is needed for the most accurate assessment of oxygenation. No indications are known for a breathing treatment or an inhaler, nor does the nurse have enough information to know whether a chest x-ray is warranted.

The nurse is reviewing the ABG results for a patient. The latest ABG shows pH 7.48, HCO3- 23 mEq/L, Paco2 25 mm Hg, Pao2 98 mm Hg. What's the correct interpretation of these lab findings?

Acute respiratory alkalosis & hyperventilation

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Ventilatory failure