Complex exam 1
potassium
3.5-5 (mEq/L)
Give Cefazolin 1h in 50 ml saline over 30 mins. Using IV tubing with a drip factor of 20 drops per ml. Find the gtts/min
33 gtts/min
hematocrit female
35-47%
WBC
4,500-11,000 (mm3)
hematocrit male
42-52%
aPTT therapeutic
60-90 seconds
calcium
8.6-10.2 (mg/dL)
increase heparin dose
<50 seconds
Antitussives-opioids teachings
Avoid hazardous activities, alcohol, and other CNS depressants
A client has a history of chronic obstructive pulmonary disease (COPD). Following a coughing episode, the client reports sudden and unrelieved shortness of breath. Which of the following is the most important for the nurse to assess? a. Respiratory rate b. Lung sounds c. Heart rate d. Skin color
Lung sounds A client with COPD is at risk for developing pneumothorax. The description given is consistent with possible pneumothorax. Though the nurse will assess all the data, auscultating the lung sounds will provide the nurse with the information if the client has a pneumothorax.
Interpret this ABG: ph 7.25 pCO2 32, HCO3 18, pO2 74
Metabolic acidosis with partial compensation and hypoxemia
respiratory alkalosis (nursing actions)
Nursing Actions: Breathe into a paper bag to rebreathe your CO2 Tranquilizer.
respiratory acidosis (nursing actions)
Nursing actions: *HELP THEM BREATHE* Raise Head of Bed Oxygen Asthma: bronchodilators Hydration, Mechanical ventilation, Antibiotics for pneumonia
Leukotriene Modifiers actions
Prevents effects of leukotrienes thereby suppresses inflammation, bronchoconstriction, airway edema, and mucous production
Glucocorticoids actions
Prevents inflammation, suppresses mucous production
What is the most common early sign of ARDS?
Rapid onset of severe dyspnea
For a patient with a chest tube to have a water-seal, the nurse should include what action in the care plan?
measuring the drainage in the collection chamber
22-26
normal HCO3 range
95-100
normal O2 saturation range
45-35
normal PaCO2 range
acidosis (electrolyte changes)
(electrolyte changes) hyperkalemia hypercalcemia
alkalosis (electrolyte changes)
(electrolyte changes) hypokalemia hypocalcemia
respiratory alkalosis (etiology)
(etiology) *hyperventilation* -fear -febrile -anxiety
respiratory acidosis (etiology)
(etiology) *hypoventilation* -decreased alveolar-capillary diffusion -pulmonary embolism -CAL- trapped CO2 in alveoli -pneumonia -decreased chest expansion -circumferential burn-eschar -binder -airway obstruction -foreign body -tumor -respiratory depression -anesthesia -opioids
metabolic acidosis (etiology)
(etiology) *increased H+ production* -DKA-fats --> ketones -starvation-fates --> ketones -lactic acidosis - anaerobid metabolism *decreased H+ elimination* -renal failure (H20) *decreased HCO3 production* -pancreatic disease -renal failure *increased HCO3 elimination* -diarrhea
pH <7.1
(pH level) myocardial depression and resistance to vasopressors (epinephrine)
Expectorants actions
-Liquifies secretions by increasing mucous production allowing expectoration of secretions -Liquifies secretions and facilitates coughing
Mucolytics actions
-Liquifies secretions by increasing mucous production allowing expectoration of secretions -Liquifies secretions and facilitates coughing
Beta2-Adrenergic Agonists Teaching
-Use this inhaler before other inhalers to increase absorption -Used in the treatment of an acute asthma attack
A client has a sucking stab wound to the chest. Which action should the nurse take first? a. Apply a dressing over the wound and tape it on three sides. b. Prepare to start an I.V. line. c. Draw blood for a hematocrit and hemoglobin level. d. Prepare a chest tube insertion tray.
Apply a dressing over the wound and tape it on three sides. The nurse should immediately apply a dressing over the stab wound and tape it on three sides to allow air to escape and to prevent tension pneumothorax (which is more life-threatening than an open chest wound). Only after covering and taping the wound should the nurse draw blood for laboratory tests, assist with chest tube insertion, and start an I.V. line.
A client on long-term mechanical ventilation becomes very frustrated when he tries to communicate. Which intervention should the nurse perform to assist the client? a. Ask a family member to interpret what the client is trying to communicate b. Ask the physician to wean the client off the mechanical ventilator to allow the client to talk c. Ask the client to write, use a picture board, or spell words with an alphabet board d. Assure the client that everything will be alright and that he shouldn't become upset.
Ask the client to write, use a picture board, or spell words with an alphabet board. If the client uses an alternative method of communication, such as writing, using a picture board, or spelling words on an alphabet board, he'll feel more in control and be less frustrated. Assuring the client that everything will be all right offers false reassurance and telling him not to be upset minimizes his feelings. Neither of these methods helps the client to communicate. Family members are also likely to encounter difficulty interpreting the wishes of a client with an endotracheal tube or tracheostomy tube. Making them responsible for interpreting the client's gestures may frustrate them. The client may be weaned off a mechanical ventilator only when the physiologic parameters for weaning have been met.
Inhaled Anticholinergics Teachings
Avoid if allergic to peanuts, use cautiously with glaucoma and BPH
A nurse is working with a client being extubated from the ventilator. Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain? a. ECG results b. CBC results c. Fluid intake for the past 24 hours d. Baseline ABG levels
Baseline arterial blood gas (ABG) levels Before weaning the client from mechanical ventilation, it's most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure. Other assessment parameters are less critical. Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. Anemic hypoxia is an issue, but would not be most important factor before weaning ECG results are documented on the client's record, and the nurse can refer to them before the weaning process begins.
Antihistamines action
Blocks histamine release during an allergic reaction
Inhaled Anticholinergics Actions
Blocks muscarinic receptors of the bronchi resulting in bronchodilation
The nurse is caring for a client following a thoracotomy. Which finding requires immediate intervention by the nurse? a. Heart rate 112 bpm b. Pain of 5 on a 10 scale c. Chest tube drainage 190 ml/hr d. Moderate amounts of colorless sputum
Chest tube drainage, 190 mL/hr The nurse should monitor and document the amount and character of drainage every 2 hours. The nurse must notify the primary provider if drainage is ≥150 mL/hr. The other findings are normal following a thoracotomy and no intervention would be required.
A nurse is caring for a patient who has been just diagnosed with lung cancer. What is a cardinal sign of lung cancer?
Cough or change in chronic cough
Antitussives- non-opioids prototypes/examples
dextromethorphan (Robitussin)
Expectorants protypes/examples
guaifenesin (Mucinex)
Inhaled Anticholinergics Prototypes/Examples
ipratropium (Atrovent), tiotropium (Spiriva)
The nurse is assisting a physician with an endotracheal intubation. It is most important for the nurse to assess?
symmetry of the patient's chest expansion
metabolic alkalosis (treatment)
treatment: treat the cause -Can give acetazolamide (Diamox) to promote urinary excretion of HCO3-
metabolic acidosis (treatment)
treatment: treat the cause DKA- insulin and fluids renal failure- dialysis lactic acidosis- increase 02 at the cellular level
The clinic nurse is caring for a client who has been diagnosed with emphysema and who has just had a pulmonary function test (PFT) ordered. The client asks, "What exactly is this test for?" What would be the nurse's best response? a. "A PFT measures how much energy you get from the oxygen you breathe." b. "A PFT measures how elastic your lungs are." c. "A PFT measures whether oxygen and carbon dioxide move between your lungs and your blood." d. "A PFT measures how much air moves in and out of your lungs when you breathe."
"A PFT measures how much air moves in and out of your lungs when you breathe." PFTs are routinely used in clients with chronic respiratory disorders. They are performed to assess respiratory function and to determine the extent of dysfunction. Such tests include measurements of lung volumes, ventilatory function, and the mechanics of breathing, diffusion, and gas exchange. Lung elasticity and diffusion can often be implied from PFTs, but they are not directly assessed. Energy obtained from respiration is not measured directly.
The client asks the nurse to explain the reason for a chest tube insertion in treating a pneumothorax. Which is the best response by the nurse? a. "Chest tube will allow air to be restored to the lung." b. "Chest tubes provide a route for medication instillation to the lung." c. "The tube will drain air from the space around the lung." d. "The tube will drain secretions from the lung."
"The tube will drain air from the space around the lung." Negative pressure must be maintained in the pleural cavity for the lungs to be inflated. An injury that allows air into the pleural space will result in a collapse of the lung. The chest tube can be used to drain fluid and blood from the pleural cavity and to instill medication, such as talc, to the cavity.
creatinine
0.7-1.4 (mg/dL)
INR normal
1
magnesium
1.3-2.3 (mg/dL)
BUN
10-20 (mg/dL)
hemoglobin female
12-16 (g/dL)
hemoglobin male
13-18 (g/dL)
sodium
135-145 (mEq/L)
platelets
150,000-450,000 (mm3)
INR therapeutic
2-3.5
phosphate
2.5-4.5 (mg/dL)
aPTT normal
21-35 seconds
decrease heparin dose
>100 seconds
A nurse would question the accuracy of a pulse oximetry evaluation in which of the following conditions? a. A client on a ventilator with PEEP b. A client experiencing hypothermia c. A client sitting in a chair after prolonged bed rest d. A client receiving oxygen therapy via venturi mask
A client experiencing hypothermia Pulse oximetry is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin. The reading is referred to as SpO2. A probe or sensor is attached to the fingertip, forehead, earlobe, or bridge of the nose. Values less than 85% indicate that the tissues are not receiving enough oxygen. SpO2 values obtained by pulse oximetry are unreliable in states of low perfusion such as hypothermia.
The nurse is caring for a respiratory client who uses a noninvasive positive pressure device. Which medical equipment does the nurse anticipate to find in the client's room? a. A face mask b. A rigid shell c. A nasal cannula d. A ventilator
A face mask A face mask or other nasal devices are found in the client's room as this type of ventilation does not require intubation or a ventilator. A rigid shell is used with a negative pressure chamber and is not frequently used today. A nasal cannula is not used with the positive pressure device.
A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for a. A cut or slice in the tubing from the ventilator b. Higher than normal endotracheal cuff pressure c. Malfunction of the alarm button d. A kink in the ventilator tubing
A kink in the ventilator tubing One event that could cause the ventilator's peak-airway-pressure alarm to sound is a kink in the ventilator tubing. After making this and other assessments without correction, then it could be a malfunction of the alarm button. Higher than normal endotracheal cuff pressure could cause client tissue damage but would not make the ventilator alarms sound. A cut or slice in the tubing from the ventilator would result in decreased pressure.
Mucolytics prototypes/examples
Acetylcysteine (Mucomyst)
Constant bubbling in the water seal of a chest drainage system indicates which problem? a. Air leak b. Tension pneumothorax c. Tidaling d. Increased drainage
Air leak The nurse needs to observe for air leaks in the drainage system; they are indicated by constant bubbling in the water seal chamber, or by the air leak indicator in dry systems with a one-way valve. Tidaling is fluctuation of the water level in the water seal that shows effective connection between the pleural cavity and the drainage chamber and indicates that the drainage system remains patent.
The nurse is caring for a client following a wedge resection. While the nurse is assessing the client's chest tube drainage system, constant bubbling is noted in the water seal chamber. This finding indicates which problem? a. Tidaling b. Increased drainage c. Tension pneumothorax d. Air leak
Air leak The nurse needs to observe for air leaks in the drainage system; they are indicated by constant bubbling in the water seal chamber, or by the air leak indicator in dry systems with a one-way valve. Tidaling is fluctuation of the water level in the water seal that shows effective connection between the pleural cavity and the drainage chamber and indicates that the drainage system remains patent.
You are a nurse caring for a client who has just had a tracheostomy. What should you monitor frequently? a. Psychologic status b. Level of consciousness c. Airway patency d. Pain level
Airway patency The nurse monitors for potential complications and checks airway patency frequently. Secretions can rapidly clog the inner lumen of the tracheostomy tube, resulting in severe respiratory difficulty or death by asphyxiation.
The nurse received a client from the post-anesthesia care unit (PACU) who has a chest tube to a closed drainage system. Report from the PACU nurse included drainage in the chest tube at 80 mL of bloody fluid. Fifteen minutes after transfer from the PACU, the chest tube indicates drainage as pictured. The client is reporting pain at "8" on a scale of 0 to 10. The first action of the nurse is to: a. Lay the client's head to a flat position b. Assess pulse and blood pressure c. Administer prescribed pain medication d. Notify the physician
Assess pulse and blood pressure. The client has bled 120 mL of bloody drainage in the chest drainage system within 15 minutes. It is most important for the nurse to assess for signs and symptoms of hemorrhage, which may be indicated by a rapid pulse and decreasing blood pressure. The nurse may then lay the client in a flat position and notify the physician.
The acute medical nurse is preparing to wean a client from the ventilator. Which assessment parameter is most important for the nurse to assess? a. Fluid intake for the last 24 hours b. ECG results c. Baseline ABG levels d. Prior outcomes of weaning
Baseline arterial blood gas (ABG) levels Before weaning a client from mechanical ventilation, it is most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure. Other assessment parameters are relevant, but less critical. Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the client's record, and the nurse can refer to them before the weaning process begins.
The emergency department (ED) nurse is caring for a client with a possible acid-base imbalance. The physician has ordered an arterial blood gas (ABG). What is one of the most important indications of an acid-base imbalance that is shown in an ABG? a. PaO2 b. Bicarbonate c. Carbonic Acid d. PO2
Bicarbonate a. Arterial blood gas (ABG) results are the main tool for measuring blood pH, CO2 content (PaCO2), and bicarbonate. An acid-base imbalance may accompany a fluid and electrolyte imbalance. PaO2 and PO2 are not indications of acid-base imbalance. Carbonic acid levels are not shown in an ABG.
Antitussives-opioids side effects
CNS and respiratory depression, constipation, abuse
Glucocorticoids side effects
Candidisis, hyperglycemia
The nurse is assessing the lungs of a patient diagnosed with pulmonary edema. Which of the following would be expected upon auscultation? a. Crackles at lung bases b. Egophony c. Absent breath sounds d. Bronchial breath sounds
Crackles at lung bases A patient with pulmonary edema would be expected to have crackles in the lung bases, and possible wheezes. Egophony may occur in patients diagnosed with pleural effusion. Absent breath sounds occurs in pneumothorax. Bronchial breath sounds occur in consolidation, such as pneumonia.
The nurse is caring for a client who is scheduled for a lobectomy for lung cancer. While assisting with a subclavian vein central line insertion, the nurse notes the client's oxygen saturation rapidly dropping. The client reports shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. What further assessment findings support the presence of a pneumothorax? a. Muffled heart sounds b. Sudden loss of consciousness c. Paradoxical chest wall movement with respirations d. Diminished or absent breath sounds of the affected side
Diminished or absent breath sounds on the affected side In the case of a simple pneumothorax, auscultating the breath sounds will reveal absent or diminished breath sounds on the affected side. Paradoxical chest wall movements occur in flail chest conditions. Sudden loss of consciousness does not typically occur.
The nurse is assessing a client who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in the water seal rises and falls in rhythm with the client's respirations. How should the nurse best respond to this assessment finding? a. Document that the chest drainage system is operating as it is intended. b. Encourage the client to do deep breathing and coughing exercises. c. Gently reinsert the chest tube 1 to 2 cm and observe if the water level stabilizes. d. Inform the physician promptly that there is in imminent leak in the drainage system.
Document that the chest drainage system is operating as it is intended. Fluctuation of the water level in the water seal shows effective connection between the pleural cavity and the drainage chamber and indicates that the drainage system remains patent. No further action is needed.
A patient is on high-flow O2 therapy for 72 hours. What symptoms suggest the client is is experiencing oxygen toxicity?
Dyspnea and substernal pain
Guaifenesin belongs to which drug class
Expectorants
A patient arrives in the emergency department after being involved in a motor vehicle accident. The nurse observes paradoxical chest movement when removing the patient's shirt. What does the nurse know that this finding indicates? a. Tension pneumothorax b. Pneumothorax c. Flail chest d. ARDS
Flail chest During inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner (pendelluft movement) in that it is pulled inward during inspiration, reducing the amount of air that can be drawn into the lungs. On expiration, because the intrathoracic pressure exceeds atmospheric pressure, the flail segment bulges outward, impairing the patient's ability to exhale. The mediastinum then shifts back to the affected side (Fig. 23-8). This paradoxical action results in increased dead space, a reduction in alveolar ventilation, and decreased compliance.
A victim of a motor vehicle accident has been brought to the emergency room. The patient is exhibiting paradoxical chest expansion and respiratory distress. Which of the following chest disorders should be suspected? a. Flail chest b. Cardiac tamponade c. Simple pneumothorax d. Pulmonary contusion
Flail chest When a flail chest exists, during inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner in that it is pulled inward during inspiration, reducing the amount of air that can be drawn into the lungs. On expiration, because the intrathoracic pressure exceed atmospheric pressure, the flail segment bulges outward, impairing the patient's ability to exhale. Cardiac tamponade is compression of the heart resulting from fluid or blood within the pericardial sac. A pulmonary contusion is damage to the lung tissues resulting in hemorrhage and localized edema. A simple pneumothorax occurs when air enters the pleural space through the rupture of a bleb or a bronchopleural fistula.
The nurse is caring for a client with multiple organ failure and in metabolic acidosis. Which pair of organs is responsible for regulatory processes and compensation? a. Pancreas and stomach b. Heart and lungs c. Kidney and liver d. Lungs and kidney
Lungs and kidney a. The lungs and kidneys facilitate the ratio of bicarbonate to carbonic acid. Carbon dioxide is one of the components of carbonic acid. The lungs regulate carbonic acid levels by releasing or conserving CO2 by increasing or decreasing the respiratory rate. The kidneys assist in acid-base balance by retaining or excreting bicarbonate ions.
A critical care nurse is caring for a client with an endotracheal tube who is on a ventilator. The nurse knows that meticulous airway management of this client is necessary. What is the main rationale for this? a. Preventing the need for suctioning b. Increasing the client's lung compliance c. Maintaining the sterility of the client's airway d. Maintaining a patent airway
Maintaining a patent airway Maintaining a patent (open) airway is achieved through meticulous airway management, whether in an emergency situation such as airway obstruction or in long-term management, as in caring for a client with an endotracheal or a tracheostomy tube. Airway management is not primarily conducted to reduce the need for suctioning, to maintain sterility or to increase compliance because none of these are important if the client's airway is not patent.
A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside? a. Oxygen analyzer b. Water-seal chest drainage set-up c. Tracheostomy cleaning kit d. Manual resuscitation bag
Manual resuscitation bag The client with COPD depends on mechanical ventilation for adequate tissue oxygenation. The nurse must keep a manual resuscitation bag at the bedside to ventilate and oxygenate the client in case the mechanical ventilator malfunctions. Because the client doesn't have chest tubes or a tracheostomy, keeping a water-seal chest drainage set-up or a tracheostomy cleaning kit at the bedside isn't necessary. Although the nurse may keep an oxygen analyzer (pulse oximeter) on hand to evaluate the effectiveness of ventilation, this equipment is less important than the manual resuscitation bag.
A client has the following arterial blood gas (ABG) values: pH, 7.12; partial pressure of arterial carbon dioxide (PaCO2), 40 mm Hg; and bicarbonate (HCO3-), 15 mEq/L. These ABG values suggest which disorder? a. Metabolic alkalosis b. Metabolic acidosis c. Respiratory acidosis d. Respiratory alkalosis
Metabolic acidosis a. This client's pH value is below normal, indicating acidosis. The HCO3- value also is below normal, reflecting an overwhelming accumulation of acids or excessive loss of base, which suggests metabolic acidosis. The PaCO2 value is normal, indicating absence of respiratory compensation. These ABG values eliminate respiratory alkalosis, respiratory acidosis, and metabolic alkalosis.
The nurse on a surgical unit is caring for a client recovering from recent surgery with the placement of a nasogastric tube to low continuous suction Which acid-base imbalance is most likely to occur? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory alkalosis d. Respiratory acidosis
Metabolic alkalosis a. Metabolic alkalosis results in increased plasma pH because of an accumulated base bicarbonate or decreased hydrogen ion concentration. Factors that increase base bicarbonate include excessive oral or parenteral use of bicarbonate-containing drugs, a rapid decrease in extracellular fluid volume and loss of hydrogen and chloride ions as with gastric suctioning. Acidotic states are from excess carbonic acid and hydrogen ions in the system. Respiratory alkalosis results from a carbonic acid deficit that occurs when rapid breathing releases more CO2 than necessary.
Methylxanthines side effects
Nausea, vomiting, restlessness, dysrhythmias, seizures
A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? a. PaCO2 b. HCO3- c. pH d. PaO2
Partial pressure of arterial oxygen (PaO2) The most significant and direct indicator of the effectiveness of oxygen therapy is the PaO2 value. Based on the PaO2 value, the nurse may adjust the type of oxygen delivery (cannula, Venturi mask, or mechanical ventilator), flow rate, and oxygen percentage. The other options reflect the client's ventilation status, not oxygenation. The pH, HCO3-, and PaCO2
A nurse is caring for a client with a chest tube. If the chest drainage system is accidentally disconnected, what should the nurse plan to do? a. Place the end of the chest tube in a container of sterile saline. b. Apply an occlusive dressing and notify the physician. c. Clamp the chest tube immediately. d. Secure the chest tube with tape.
Place the end of the chest tube in a container of sterile saline. If a chest drainage system is disconnected, the nurse may place the end of the chest tube in a container of sterile saline or water to prevent air from entering the chest tube, thereby preventing negative respiratory pressure. The nurse should apply an occlusive dressing if the chest tube is pulled out — not if the system is disconnected. The nurse shouldn't clamp the chest tube because clamping increases the risk of tension pneumothorax. The nurse should tape the chest tube securely to prevent it from being disconnected, rather than taping it after it has been disconnected.
The nurse is assessing an adult client following a motor vehicle accident. The nurse observes that the client has an increased use of accessory muscles and is reporting chest pain and shortness of breath. The nurse should recognize the possibility of what condition? a. Pneumothorax b. Aspiration c. Cardiac ischemia d. Acute bronchitis
Pneumothorax If the pneumothorax is large and the lung collapses totally, acute respiratory distress occurs. The client is anxious, has dyspnea and air hunger, has increased use of the accessory muscles, and may develop central cyanosis from severe hypoxemia. These symptoms are not definitive of pneumothorax, but because of the client's recent trauma they are inconsistent with cardiac ischemia, bronchitis, or aspiration.
A RN is planning care for 4 patients and is assigning tasks to a LPN and a CNA. What task is appropriate for the LPN?
Reinforce patient teaching for enoxaparin therapy
Methylxanthines actions
Relaxes bronchial smooth muscle resulting in bronchodilation
The nurse is caring for a client who is ready to be weaned from the ventilator. In preparing to assist in the collaborative process of weaning, the nurse should anticipate that the weaning of the client will progress in what order? a. Removal of the tube, oxygen, and then ventilator b. Removal from the ventilator, tube, and then oxygen c. Removal from oxygen, ventilator, and then tube d. Removal from oxygen, tube, then ventilator
Removal from the ventilator, tube, and then oxygen The process of withdrawing the client from dependence on the ventilator takes place in three stages: the client is gradually removed from the ventilator, then from the tube, and, finally, oxygen.
A client who is being treated for pneumonia reports sudden shortness of breath. An arterial blood gas (ABG) is drawn. The ABG has the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect? a. Respiratory acidosis b. Metabolic acidosis c. Metabolic alkalosis d. Respiratory alkalosis
Respiratory acidosis The pH is below 7.40, PaCO2 is greater than 40, and the HCO3 is normal; therefore, it is a respiratory acidosis, and compensation by the kidneys has not begun, which indicates this was probably an acute event. The HCO3 of 24 is within the normal range so it is not metabolic alkalosis. The pH of 7.21 indicates an acidosis, not alkalosis. The pH of 7.21 indicates it is an acidosis but the HCO3 of 24 is within the normal range, ruling out metabolic acidosis.
A nurse reviews the arterial blood gas (ABG) values of a client admitted with pneumonia: pH, 7.51; PaCO2, 28 mm Hg; PaO2, 70 mm Hg; and HCO3--, 24 mEq/L. What do these values indicate? a. Respiratory acidosis b. Metabolic alkalosis c. Metabolic acidosis d. Respiratory alkalosis
Respiratory alkalosis A client with pneumonia may hyperventilate in an effort to increase oxygen intake. Hyperventilation leads to excess carbon dioxide (CO2) loss, which causes alkalosis — indicated by this client's elevated pH value. With respiratory alkalosis, the kidneys' bicarbonate (HCO3-) response is delayed, so the client's HCO3- level remains normal. The below-normal value for the partial pressure of arterial carbon dioxide (PaCO2) indicates CO2 loss and signals a respiratory component. Because the HCO3- level is normal, this imbalance has no metabolic component. Therefore, the client is experiencing respiratory alkalosis.
A nurse is caring for a client after a lung biopsy. Which assessment finding requires immediate intervention? a. O2 Sat of 96% on 3L of O2 b. RR of 44 breaths/min c. Client stating pain level of 7 out of 10 that decreases with pain medication d. Client dozing when left alone but wakening easily
Respiratory rate of 44 breaths/minute a. A respiratory rate of 44 breaths/minute is significant and requires immediate intervention. The client may be experiencing postoperative complications, such as pneumothorax or bleeding. An oxygen saturation level of 96% on 3 L of oxygen, a pain level of 7 out of 10 that decreases with pain medication, and dozing when left alone are normal and don't require further intervention.
Beta2-Adrenergic Agonists actions
Selectively activates the Beta2 receptors resulting in bronchodilation
A client who has an altered level of consciousness is receiving tube feedings. Clients receiving tube feeding should be placed in which position? a. Supine b. Trendelenburg c. Semi-fowler's or higher d. Side-lying
Semi-Fowler's or higher Clients receiving tube feedings are positioned with the head of the bed at 30 degrees or higher during feedings and for 30 to 45 minutes after tube feedings. Clients receiving oral feedings are positioned with the head of the bed in an upright position for 30 to 45 minutes after feedings. For clients with a nasogastric or gastrostomy tube, the placement of the tube and residual gastric volume must be checked before each
Mucolytics teaching
Smells like rotten eggs
Mast Cell Stabilizers actions
Stabilizes mast cells inhibiting the release of histamine
The critical care nurse and the other members of the care team are assessing the client to see if he is ready to be weaned from the ventilator. What are the most important predictors of successful weaning that the nurse should identify? a. Normal orientation and level of consciousness b. Stable nutritional status and ABGs c. Stable vital signs and ABGs d. Pulseox above 80 and stable vital signs
Stable vital signs and ABGs Among many other predictors, stable vital signs and ABGs are important predictors of successful weaning. Pulse oximetry must greatly exceed 80%. Nutritional status is important, but vital signs and ABGs are even more significant. Clients who are weaned may or may not have full level of consciousness.
A nurse is performing trach care for a patient and suctioning to remove secretions. What action should the nurse take?
Suction 2-3 times with a 60 second pause between passes
A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do? a. Suction the client's artificial airway b. Check for an apical pulse c. Ventilate the client with the handheld mechanical ventilator d. Increase the oxygen percentage
Suction the client's artificial airway. A high-pressure alarm on a continuous mechanical ventilator indicates an obstruction in the flow of gas from the machine to the client. The nurse should suction the client's artificial airway to remove respiratory secretions that could be causing the obstruction. The sounding of a ventilator alarm has no relationship to the apical pulse. Increasing the oxygen percentage and ventilating with a handheld mechanical ventilator wouldn't correct the airflow blockage.
Antitussives- non-opioids actions
Suppresses cough through its action on the CNS
Antitussives-opioids actions
Suppresses cough through its action on the CNS
Methylxanthines Teaching
Swallow sustained-release capsules whole
Beta2-Adrenergic Agonists side effects
Tachycardia, tremors
Glucocorticoids teachings
Taper dose when discontinuing the medication
The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation? a. Cardiac tamponade b. Flail chest c. Pulmonary contusion d. Tension pneumothorax
Tension pneumothorax Clamping can result in a tension pneumothorax. The other options would not occur if the chest tube was clamped during transportation.
A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? a. The system is functioning normally b. The system has an air leak c. The chest tube is obstructed d. The client has a pneumothorax
The system has an air leak. Constant bubbling in the water-seal chamber indicates an air leak and requires immediate intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. Clients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the fluid would stop fluctuating in the water-seal chamber.
While caring for a client with a chest tube, which nursing assessment would alert the nurse to a possible complication? a. Absence of bloody drainage in the anterior/upper tube b. The tissues give a crackling sensation when palpated c. Bloody drainage is observed in the collection chamber d. Skin around tube is pink
The tissues give a crackling sensation when palpated. Subcutaneous emphysema is the result of air leaking between the subcutaneous layers. It is not a serious complication but is notable and reportable. Pink skin and blood in the collection chamber are normal findings. When two tubes are inserted, the posterior or lower tube drains fluid, whereas the anterior or upper tube is for air removal.
A client is being mechanically ventilated in the ICU. The ventilator alarms begin to sound. The nurse should complete which action first? a. Reposition the endotracheal tube b. Troubleshoot to identify the malfunction c. Notify the respiratory therapist d. Manually ventilate the client
Troubleshoot to identify the malfunction. The nurse should first immediately attempt to identify and correct the problem; if the problem cannot be identified and/or corrected, the client must be manually ventilated with an Ambu bag. The respiratory therapist may be notified, but this is not the first action by the nurse. The nurse should not reposition the endotracheal tube as a first response to an alarm.
Which type of ventilator has a preset volume of air to be delivered with each inspiration? a. Time-cycled b. Pressure-cycled c. Negative-pressure d. Volume-controlled
Volume-controlled With volume-controlled ventilation, the volume of air to be delivered with each inspiration is preset. Negative-pressure ventilators exert a negative pressure on the external chest. Time-cycled ventilators terminate or control inspiration after a preset time. When the pressure-cycled ventilator cycles on, it delivers a flow of air (inspiration) until it reaches a preset pressure, and then cycles off, and expiration occurs passively.
After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes? a. Suction control chamber b. Water-seal chamber c. Collection chamber d. Air-leak chamber
Water-seal chamber Fluctuations in the water-seal compartment are called tidal movements and indicate normal function of the system as the pressure in the tubing changes with the client's respirations. The air-leak meter — not chamber — detects air leaking from the pleural space. The collection chamber connects the chest tube from the client to the system. Drainage from the tube drains into and collects in a series of calibrated columns in this chamber. The suction control chamber provides the suction, which can be controlled to provide negative pressure to the chest.
On auscultation, what finding suggests a right pneumothorax?
absence of breath sounds in the right thorax area
Beta2-Adrenergic Agonists Prototypes/Examples
albuterol (Ventolin)
Glucocorticoids prototypes/examples
beclomethasone, prednisone
respiratory alkalosis (causes)
causes: hyperventilation (anxiety, fear, PE) mechanical ventilation
respiratory acidosis (causes)
causes: respiratory stimuli (anesthesia, drug overdose) COPD asthma pneumonia atelectasis
A nurse is caring for a patient with DVT. What finding suggests pulmonary embolism?
chest pain and dyspnea
A client with emphysema is at a greater risk for developing which acid-base imbalance? a. Metabolic acidosis b. Chronic respiratory acidosis c. Metabolic alkalosis d. Respiratory Alkalosis
chronic respiratory acidosis a. Respiratory acidosis, which may be either acute or chronic, is caused by excess carbonic acid, which causes the blood pH to drop below 7.35. Chronic respiratory acidosis is associated with disorders such as emphysema, bronchiectasis, bronchial asthma, and cystic fibrosis.
Antitussives-opioids prototypes/examples
codeine, hydrocodone
Mast Cell Stabilizers prototypes/examples
cromolyn sodium (Intal)
The nurse is completing a physical assessment of a client's trachea. The nurse inspects and palpates the trachea for a. Color of the mucous membranes b. Evidence of exudate c. Deviation from the midline d. Evidence of muscle weakness
deviation from the midline. During the physical examination, the nurse must inspect and gently palpate the trachea to assess for placement and deviation from the midline. The trachea is normally in the midline as it enters the thoracic inlet behind the sternum, but it may be deviated by a mass in the neck or mediastinum. Pulmonary disorders, such as a pneumothorax or pleural effusion, may also displace the trachea. The nurse examines the posterior pharynx and tonsils with a tongue blade and light, and notes any evidence of swelling, inflammation, or exudate, as well as changes in color of the mucous membranes. The nurse also examines the anterior, posterior, and lateral chest walls for any evidence of muscle weakness.
Antihistamines prototype/examples
diphenhydramine (Benadryl), citirizine (Zyrtec)
acetazolamide (diamox)
diuretic used to treat metabolic alkalosis. given IV (sometimes oral) excretes bicarbonate
metabolic alkalosis (etiology)
etiology: *increased HCO3 intake* - antacids *increased H+ elimination* -vomiting -gastric suctioning
It is best to clamp a chest tube when transporting a patient.
false
For a water seal system, suction is usually set at 100 cm H2O.
false (-20 cm)
The purpose of the water seal is to prevent the introduction of organisms into the pleural space.
false (air)
To detect the reoccurrence of a pneumothorax, expect the patient to undergo an echocardiogram.
false (chest xray)
A patient with a pneumothorax (PTX) can have respiratory distress and rhonchi on the side of the collapsed lung.
false (decreased breath sounds)
Fractures of the lower ribs are associated with perforation of the large intestine.
false (liver and spleen)
The insertion of a chest tube into the pleural space restores the positive intrathoracic pressure needed for lung re-expansion after surgery or trauma.
false (negative pressure)
Most rib fractures are treated conservatively with surgical intervention.
false (no surgical interventions)
Pain with inspiration is the classical sign of a flail chest injury.
false (paradoxical movement of detached segment of rib- pulled inward on inspiration, bulges outward during expiration)
During chest tube removal, the nurse should have the patient breathe deeply.
false (perform valsalva maneuver)
A patient undergoing a chest tube insertion for a pneumothorax should be placed in the lateral position.
false (sitting forward, leaning over, or lateral supine)
All patients with a pneumothorax will have a chest tube inserted.
false (small pneumothorax may spontaneously resolve)
When palpating around your patient's chest tube insertion site, you detect crepitus. Tension pneumothorax should be suspected.
false (subcutaneous emphysema)
Spontaneous pneumothorax typically affects women in their forties.
false (thin men between 20-40)
A pulmonary function test is the diagnostic test of choice to rule out a PTX.
false (xray and ABGs)
A client with a history of anxiety experiences respiratory alkalosis. The nurse measures a respiratory rate of 46 breaths/minute, a heart rate of 110 beats/minute, a blood pressure of 162/90 mm Hg, and a temperature of 98.6° F (37° C). To help correct respiratory alkalosis, the nurse should: a. Administer antibiotics as ordered b. Insert an NG tube as ordered c. Administer acetaminophen as ordered d. Instruct the client to breathe into a paper bag
instruct the client to breathe into a paper bag. a. A client with a history of anxiety who experiences respiratory alkalosis should breathe into a paper bag to increase arterial carbon dioxide tension and ease anxiety (which may exacerbate the alkalosis). An NG tube would be indicated for a client with metabolic alkalosis secondary to ingestion of toxic substances; there is no reason to believe that this has occurred. Fever may cause metabolic (not respiratory) alkalosis and would be treated with acetaminophen. A client with sepsis also may have metabolic alkalosis and probably would receive antibiotics; however, this clinical situation doesn't suggest sepsis.
A client has been newly diagnosed with emphysema. The nurse should explain to the client that by definition, ventilation: a. Helps people who cannot breathe on their own b. Provides a blood supply to the lungs c. Is breathing air in and out of the lungs d. Is when the body changes oxygen into CO2
is breathing air in and out of the lungs. Ventilation is the actual movement of air in and out of the respiratory tract. Diffusion is the exchange of oxygen and CO2 through the alveolar-capillary membrane. Pulmonary perfusion refers to the provision of blood supply to the lungs. A mechanical ventilator assists patients who are unable to breathe on their own.
Leukotriene Modifiers prototypes/actions
montelukast (Singulair)
Mucolytics side effects
nausea and vomiting
80-100
normal PaO2 range
7.35-7.45
normal pH range
To confirm an acid-base imbalance, it is necessary to assess which findings from a client's arterial blood gas (ABG) results? Select all that apply. a. K+ b. PaCO2 c. HCO3 d. Na+ e. Glucose f. pH
pH, PaCO2, HCO3 Arterial blood gas (ABG) results are the main tool for measuring blood pH, CO2 content (PaCO2), and bicarbonate (HCO3). The two types of acid-base imbalances are acidosis and alkalosis.
The nurse is analyzing the arterial blood gas (ABG) results of a client diagnosed with severe pneumonia. Which of the following ABG results indicates respiratory acidosis? a. pH: 7.32, PaCO2: 40 mm Hg, HCO3-: 18 mEq/L b. pH: 7.50, PaCO2: 30 mm Hg, HCO3-: 24 mEq/L c. pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L d. pH: 7.42, PaCO2: 45 mm Hg, HCO3-: 22 mEq /L
pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L Respiratory acidosis is a clinical disorder in which the pH is less than 7.35 and the PaCO2 is greater than 42 mm Hg and a compensatory increase in the plasma HCO3- occurs. It may be either acute or chronic. The ABG of pH: 7.32, PaCO2: 40 mm Hg, HCO3-: 18 mEq/L indicates metabolic acidosis. The ABGs of pH: 7.50, PaCO2: 30 mm Hg, and HCO3-: 24 mEq/L indicate respiratory alkalosis. The ABGs of pH 7.42, PaCO2: 45 mm Hg, and HCO3-: 22 mEq/L indicate a normal result/no imbalance.
A physician stated to the nurse that the client has fluid in the pleural space and will need a thoracentesis. The nurse expects the physician to document this fluid as a. Pneumothorax b. Hemothorax c. Consolidation d. Pleural effusion
pleural effusion. Fluid accumulating within the pleural space is called a pleural effusion. A pneumothorax is air in the pleural space. A hemothorax is blood within the pleural space. Consolidation is lung tissue that has become more solid in nature as a result of the collapse of alveoli or an infectious process.
lungs
regulate CO2 breathe it out -works fast
kidneys
regulate metabolic pH make new HCO3 excrete HCO3 increase excretion of H+ -work slow
A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects: a. Metabolic alkalosis b. Respiratory alkalosis c. Respiratory acidosis d. Metabolic acidosis
respiratory alkalosis. a. This client's above-normal pH value indicates alkalosis. The below-normal PaCO2 value indicates acid loss via hyperventilation; this type of acid loss occurs only in respiratory alkalosis. These ABG values wouldn't occur in metabolic acidosis, respiratory acidosis, or metabolic alkalosis.
respiratory alkalosis (s/s)
s/s: *lightheadedness* *fingers tingling* deep rapid breathing tachycardia lethargy and confusion N/V
metabolic acidosis (s/s)
s/s: headache warm flushed skin N/V kussmaul respirations muscle twitching ketones in urine
respiratory acidosis (s/s)
s/s: tachycardia tachypnea mental confusion somnolent rapid shallow respirations headache dyspnea muscle weakness dysrhythmias
metabolic alkalosis (s/s)
s/s: tingling fingertips dizziness restlessnes followed by lethargy confusion N/V/D tremors, muscle cramps
Methylxanthines Prototypes/Examples
theophylline
A chest tube is inserted to treat a tension pneumothorax.
true
A flail chest occurs when ribs become "free-floating" after trauma.
true
A patient with a flail chest may need mechanical ventilation while waiting for the ribs to heal to provide chest stability.
true
A patient with fractured ribs may report a sharp pain with coughing or a deep breath.
true
A patient's chest tube has stopped fluctuating. The nurse checks and there are no kinks in the tubing. Another common reason for the chest tube to stop fluctuating is that the lung has re-expanded.
true
A pneumothorax is where air enters the pleural space and a hemothorax is where blood enters the pleural space.
true
A tension pneumothorax involves trapped air that accumulates causing a mediastinal shift putting pressure on the heart, esophagus and trachea
true
Chest tube systems and respiratory status should be assessed a minimum of every 4 hours.
true
Continuous bubbling in the water seal chamber is a sign of an air leak.
true
Drainage from the chest tube is included in the person's I & O.
true
Lung contusion and atelectasis that often accompany a flail chest are typically what is treated.
true
Rib fractures are the most common type of chest trauma.
true
Since air rises, high chest tubes (2nd ICS) drain air while low chest tubes (5th ICS) drain fluid
true
Sterile petrolatum gauze and padded clamps should be placed at the bedside.
true
The closed chest drainage system that uses wet suction contains 3 chambers: water seal, drainage chamber and wet suction chamber.
true
The correct order for a chest tube dressing (from chest wall out) is petrolatum gauze, fenestrated gauze, occlusive gauze, tape.
true
The purpose of a chest tube system can include the re-expansion of the lung after a thoracotomy and to remove air, fluid and blood.
true
Tidaling, or fluctuation, reflects proper functioning of the chest tube.
true
When an air leak is suspected, the nurse should clamp the tubing at intervals to identify the location of the air leak.
true
