E1: Respiratory
Which oxygen delivery device is considered a low-flow system? a. Nasal cannula b. Simple face mask c. Reservoir cannula d. Air-entrainment nebulizer
ANS: A A low-flow oxygen delivery system provides supplemental oxygen directly into the patient's airway at a flow of 8 L/min or less. Because this flow is insufficient to meet the patient's inspiratory volume requirements, it results in a variable FiO2 as the supplemental oxygen is mixed with room air. A nasal cannula is a low-flow oxygen delivery system.
What condition develops when air enters the pleural space from the lung on inhalation and cannot exit on exhalation? a. Tension pneumothorax b. Sucking chest wound c. Open pneumothorax d. Pulmonary interstitial empyema
ANS: A A tension pneumothorax develops when air enters the pleural space from either the lung or the chest wall on inhalation and cannot escape on exhalation. Open pneumothorax is a laceration in the parietal pleura that allows atmospheric air to enter the pleural space; it occurs as a result of penetrating chest trauma. Pulmonary interstitial emphysema is air in the pulmonary interstitial space.
Which route for endotracheal (ET) tube placement is usually used in an emergency intubation? a. Orotracheal b. Nasotracheal c. Nasopharyngeal d. Trachea
ANS: A An endotracheal tube (ETT) may be placed through the orotracheal or the nasotracheal route. In most situations involving emergency placement, the orotracheal route is used because it is simpler and allows the use of a larger diameter ETT. Nasotracheal intubation provides greater patient comfort over time and is preferred in patients with a jaw fracture.
Which statement describes the assist-control mode of ventilation? a. It delivers gas at preset volume, at a set rate, and in response to the patient's inspiratory efforts. b. It delivers gas at a preset volume, allowing the patient to breathe spontaneously at his or her own volume. c. It applies positive pressure during both ventilator breaths and spontaneous breaths. d. It delivers gas at preset rate and tidal volume regardless of the patient's inspiratory efforts.
ANS: A Continuous mandatory (volume or pressure) ventilation (CMV), also known as assist-control (AC) ventilation, delivers gas at preset tidal volume or pressure (depending on selected cycling variable) in response to patient's inspiratory efforts and initiates breath if patient fails to do so within preset time.
A patient has the following arterial blood gas (ABG) values: pH, 7.20; PaO2, 106 mm Hg; pCO2, 35 mm Hg; and , 11 mEq/L. What symptom would be most consistent with the ABG values? a. Diarrhea b. Shortness of breath c. Central cyanosis d. Peripheral cyanosis
ANS: A Diarrhea is one mechanism by which the body can lose large amounts of . The other choices are indications of hypoxia, which is not indicated with a PaO2 of 106 mm Hg.
A patient is admitted with diminished to absent breath sounds on the right side, tracheal deviation to the left side, and asymmetric chest movement. These findings are indicative of which disorder? a. Tension pneumothorax b. Pneumonia c. Pulmonary fibrosis d. Atelectasis
ANS: A Diminished to absent breath sounds on the right side, tracheal deviation to the left side, and asymmetric chest movement are indicative of tension pneumothorax.
A patient was admitted following an aspiration event on the medical-surgical floor. The patient is receiving 40% oxygen via a simple facemask. The patient has become increasingly agitated and confused. The patient's oxygen saturation has dropped from 92% to 84%. The nurse notifies the practitioner about the change in the patient's condition. What interventions should the nurse anticipate? a. Intubation and mechanical ventilation b. Change in antibiotics orders c. Suction and reposition the patient d. Orders for a sedative
ANS: A Given the significant drop in oxygen saturation, increasing agitation and confusion, the nurse should anticipate the patient will need to be intubated and mechanically ventilated. Administering antibiotics, suctioning and repositioning, and administering a sedative would not address the development of severe hypoxemia.
When assessing a patient, the use of observation is referred to as what technique? a. Inspection b. Palpation c. Percussion d. Auscultation
ANS: A Inspection is the process of looking intently at the patient. Palpation is the process of touching the patient to judge the size, shape, texture, and temperature of the body surface or underlying structures. Percussion is the process of creating sound waves on the surface of the body to determine abnormal density of any underlying areas. Auscultation is the process of concentrated listening with a stethoscope to determine characteristics of body functions.
Which range would be considered normal for pulmonary artery systolic pressures? a. 15 to 30 mm Hg b. 4 to 12 mm Hg c. 25 to 35 mm Hg d. 1 to 11 mm Hg
ANS: A Pulmonary artery systolic pressure ranges from 15 to 30 mm Hg, pulmonary artery diastolic pressure ranges from 4 to 12 mm Hg, and pulmonary artery mean pressure ranges from 9 to 18 mm Hg. Pulmonary hypertensions is defined as pulmonary artery systolic pressure of greater than 35 mm Hg.
A patient is admitted with acute lung failure secondary to pneumonia. Arterial blood gas (ABG) values on the current ventilator settings are pH, 7.37; PaCO2, 50 mm Hg; and HCO3 ̄, 27 mEq/L. What is the correct interpretation of the patient's ABG values? a. Compensated respiratory acidosis b. Compensated metabolic alkalosis c. Uncompensated respiratory alkalosis d. Uncompensated metabolic acidosis
ANS: A The ABG values reflect a compensated respiratory acidosis. Values include a pH of 7.35 to 7.39, PaCO2 above 45 mm Hg, and above 26 mEq/L. Uncompensated respiratory alkalosis values include a pH below 7.35, PaCO2 above 45 mm Hg, and of 22 to 26 mEq/L. Compensated metabolic alkalosis values include a pH of 7.41 to 7.45, PaCO2 above 45 mm Hg, and above 26 mEq/L. Uncompensated metabolic acidosis values include a pH above 7.35, PaCO2 of 35 to 45 mm Hg, and below 22 mEq/L.
When assessing an intubated patient, the nurse notes normal breath sounds on the right side of the chest and absent breath sounds on the left side of the chest. What problem should the nurse suspect? a. Right mainstem intubation b. Left pneumothorax c. Right hemothorax d. Gastric intubation
ANS: A The finding of normal breath sounds on the right side of the chest and absent breath sounds on the left side of the chest in a newly intubated patient is probably caused by a right mainstem intubation.
The oxygen saturation of a healthy individual rarely reaches 100% on room air. This can best be explained by what concept? a. Physiologic shunting b. Alveolar capillary diffusion c. Collateral air passages d. Anatomic dead space
ANS: A The mixing of venous blood from the bronchial circulation with the oxygenated blood in the left atrium decreases the saturation of left atrial blood to a range between 96% and 99%. This is referred to as physiologic shunting. For this reason, while a person is breathing room air, the oxygen saturation of arterial blood is less than 100%.
On admission, a patient presents with a respiratory rate of 28 breaths/min, heart rate of 108 beats/min in sinus tachycardia, and a blood pressure of 140/72 mm Hg. The patient's arterial blood gas (ABG) values on room air are PaO2, 60 mm Hg; pH, 7.32; PaCO2, 45 mm Hg; and , 26 mEq/L. What action should the nurse anticipate for this patient? a. Initiate oxygen therapy. b. Prepare for emergency intubation. c. Administer 1 ampule of sodium bicarbonate. d. Initiate capnography.
ANS: A The patient is hypoxemic and oxygen therapy should be initiated at this time. The patient's arterial blood gas (ABG) values do not warrant intubation at this time. Sodium bicarbonate is not indicated because this patient has a normal bicarbonate level. Capnography would not be indicated at this time as the patient's CO2 is normal. A repeat ABG may be ordered to assess the patient's ongoing respiratory status.
Ventilation-perfusion (V/Q) scans are ordered to evaluate the possibility of which of the following? a. Pulmonary emboli b. Acute myocardial infarction c. Emphysema d. Acute respiratory distress syndrome
ANS: A This test is ordered for the evaluation of pulmonary emboli. Electrocardiography or cardiac enzymes are ordered to evaluate for myocardial infarction; arterial blood gas analysis, chest radiography, and pulmonary function tests are ordered to evaluate for emphysema. Chest radiography and hemodynamic monitoring are ordered for evaluation of acute respiratory distress syndrome.
A patient presents moderately short of breath and dyspneic. A chest radiographic examination reveals a large right pleural effusion with significant atelectasis. The practitioner would be most likely to prescribe which procedure? a. Thoracentesis b. Bronchoscopy c. Ventilation-perfusion (V/Q) scan d. Repeat chest radiograph
ANS: A Thoracentesis is a procedure that can be performed at the bedside for the removal of fluid or air from the pleural space. It is used most often as a diagnostic measure; it may also be performed therapeutically for the drainage of a pleural effusion or empyema. No evidence is present that would necessitate a V/Q scan. A bronchoscopy cannot assist in fluid removal. A problem with this chest radiograph is not indicated.
A patient presents with absent lung sounds in the left lower lung fields, moderate shortness of breath, and dyspnea. The nurse suspects pneumothorax and notifies the practitioner. Orders for a STAT chest radiography and reading are obtained. Which finding best supports the nurse's suspicions? a. Blackness in the left lower lung area b. Whiteness in the left lower lung area c. Blunted costophrenic angles d. Elevated left hemidiaphragm
ANS: A With a pneumothorax, the pleural edges become evident as one looks through and between the images of the ribs on the film. A thin line appears just parallel to the chest wall, indicating where the lung markings have pulled away from the chest wall. In addition, the collapsed lung will be manifested as an area of increased density separated by an area of radiolucency (blackness).
A patient just involved in a motor vehicle accident has sustained blunt chest trauma as part of his injuries. The nurse notes absent breath sounds on the left side. A left-sided pneumothorax is suspected and is further validated when assessment of the trachea reveals what finding? a. A shift to the right b. A shift to the left c. No deviation d. Subcutaneous emphysema
ANS: A With a pneumothorax, the trachea shifts to the opposite side of the problem; with atelectasis, the trachea shifts to the same side as the problem. Subcutaneous emphysema is more commonly related to a pneumomediastinum and is not specifically related to the trachea but to air trapped in the mediastinum and general neck area.
Place the steps for analyzing arterial blood gases in the proper order. 1. Assess level for metabolic abnormalities 2. Assess PaO2 for hypoxemia 3. Examine PaCO2 for acidosis or alkalosis 4. Re-examine pH to determine level of compensation 5. Examine pH for acidemia or alkalemia a. 5, 1, 2, 4, 3 b. 2, 5, 3, 1, 4 c. 1, 2, 4, 3, 5 d. 1, 3, 4, 5, 2
ANS: B A methodic approach when assessing arterial blood gases allows the nurse to detect subtle changes. A methodic approach includes look at the PaO2 level, look at the pH level, look at the PaCO2 level, look at the , and look again at the pH level.
A bronchoscopy is indicated for a patient with what condition? a. Pulmonary edema b. Ineffective clearance of secretions c. Upper gastrointestinal bleed d. Instillation of surfactant
ANS: B Bronchoscopy visualizes the bronchial tree. If secretions are present, they can be removed by suctioning and sent for culture to help adjust antibiotic therapy.
When auscultating a patient's lungs, the nurse notes breath sounds that sound like popping in the small airways. What should the nurse document in the patient's record? a. Sonorous wheezes b. Crackles c. Sibilant wheezes d. Pleural friction rub
ANS: B Crackles or rales are short, discrete, popping or crackling sounds produced by fluid in the small airways or alveoli.
A patient with acute lung failure has been on a ventilator for 3 days and is being considered for weaning. When entering the room, the ventilator inoperative alarm sounds. What action should the nurse take FIRST? a. Troubleshoot the ventilator until the problem is found. b. Take the patient off the ventilator and manually ventilate. c. Call the respiratory therapist for help. d. Silence the ventilator alarms until the problem is resolved.
ANS: B Ensure emergency equipment is at bedside at all times (eg, manual resuscitation bag connected to oxygen, masks, suction equipment or supplies), including preparations for power failures. If the ventilator malfunctions, the patient should be removed from the ventilator and ventilated manually with a manual resuscitation bag.
Which factor will result in a shift of the oxyhemoglobin dissociation curve to the left? a. Increased PaCO2 b. Increased pH c. Increased temperature d. Increased 2,3-DPG
ANS: B Factors shifting the curve to the left are increased pH, decreased PaCO2, decreased temperature, and decreased 2,3-DPG.
Which patient would be considered hypoxemic? a. A 70-year-old man with a PaO2 of 72 b. A 50-year-old woman with a PaO2 of 65 c. An 84-year-old man with a PaO2 of 96 d. A 68-year-old woman with a PaO2 of 80
ANS: B Normal PaO2 is 80 to 100 mm Hg in persons younger than 60 years. The formula for determining PaO2 for a person older than 60 years of age is 80 mm Hg minus 1 mm Hg for every year of age above 60 years of age, for example, 70 years old = 80 mm Hg - 10 mm Hg = 70 mm Hg; 84 years old = 80 mm Hg - 20 mm Hg = 60 mm Hg; and 68 years old = 80 mm Hg - 8 mm Hg = 72 mm Hg.
Patient safety precautions when working with oxygen include which action? a. Observing for signs of oxygen-associated hyperventilation b. Ensuring the oxygen device is properly positioned c. Removal of all oxygen devices when eating d. Administration of oxygen at the nurse's discretion
ANS: B Patient safety precautions when working with oxygen involve administration of oxygen and monitoring of its effectiveness. Activities include restricting smoking, administering supplemental oxygen as ordered, observing for signs of oxygen-induced hypoventilation, monitoring the patient's ability to tolerate removal of oxygen while eating, and changing the oxygen delivery device from a mask to nasal prongs during meals as tolerated.
What is the major hemodynamic consequence of a massive pulmonary embolus? a. Increased systemic vascular resistance leading to left heart failure b. Pulmonary hypertension leading to right heart failure c. Portal vein blockage leading to ascites d. Embolism to the internal carotids leading to a stroke
ANS: B The major hemodynamic consequence of a pulmonary embolus is the development of pulmonary hypertension, which is part of the effect of a mechanical obstruction when more than 50% of the vascular bed is occluded. In addition, the mediators released at the injury site and the development of hypoxia cause pulmonary vasoconstriction, which further exacerbates pulmonary hypertension.
A trauma victim has sustained right rib fractures and pulmonary contusions. Auscultation reveals decreased breath sounds on the right side. Bulging intercostal muscles are noted on the right side. Heart rate (HR) is 130 beats/min, respiratory rate (RR) is 32 breaths/min, and breathing is labored. In addition to oxygen administration, what procedure should the nurse anticipate? a. Thoracentesis b. Chest tube insertion c. Pericardiocentesis d. Emergent intubation
ANS: B The patient is experiencing a pneumothorax and will need immediate chest tube insertion. Chest tubes are inserted into the pleural space to remove fluid or air, reinstate the negative intrapleural pressure, and re-expand a collapsed lung.
Which ventilator phase variable initiates the change from exhalation to inspiration? a. Cycle b. Trigger c. Flow d. Pressure
ANS: B The phase variable that initiates the change from exhalation to inspiration is called the trigger. Breaths may be pressure triggered or flow triggered based on the sensitivity setting of the ventilator and the patient's inspiratory effort or time triggered based on the rate setting of the ventilator.
A patient was admitted with acute lung failure. The patient has been on a ventilator for 3 days and is being considered for weaning. Which criteria would indicate that the patient is ready to be weaned? a. FiO2 greater than 50% b. Rapid shallow breathing index less than 105 c. Minute ventilation greater than 10 L/min d. Vital capacity/kg greater than or equal to 15 mL.
ANS: B The rapid shallow breathing index (RSBI) has been shown to be predictive of weaning success. To calculate the RSBI, the patient's respiratory rate and minute ventilation are measured for 1 minute during spontaneous breathing. The measured respiratory rate is then divided by the tidal volume (expressed in liters). An RSBI less than 105 is considered predictive of weaning success. If the patient meets criteria for weaning readiness and has an RSBI less than 105, a spontaneous breathing trial can be performed
Which finding confirms the diagnosis of a pulmonary embolism (PE)? a. Low-probability ventilation-perfusion (V/Q) scan b. Negative pulmonary angiogram c. High-probability V/Q scan d. Absence of vascular markings on the chest radiograph
ANS: C A definitive diagnosis of a pulmonary embolism requires confirmation by a high-probability ventilation-perfusion (V/Q) scan, an abnormal pulmonary angiogram or computed tomography scan, or strong clinical suspicion coupled with abnormal findings on lower extremity deep venous thrombosis studies.
What is the medical treatment for a pneumothorax greater than 15%? a. Systemic antibiotics to treat the inflammatory response b. An occlusive dressing to equalize lung pressures c. Interventions to evacuate the air from the pleural space d. Mechanical ventilation to assist with re-expansion of the collapsed lung
ANS: C A pneumothorax greater than 15% requires intervention to evacuate the air from the pleural space and facilitate re-expansion of the collapsed lung. Interventions include aspiration of the air with a needle and placement of a small-bore (12 to 20 Fr) or large-bore (24 to 40 Fr) chest tube.
What does an intrapulmonary shunting value of 35% indicate? a. Normal gas exchange of venous blood b. An abnormal finding indicative of a shunt-producing disorder c. A serious and potentially life-threatening condition d. Metabolic alkalosis
ANS: C A shunt greater than 10% is considered abnormal and indicative of a shunt-producing disorder. A shunt greater than 30% is a serious and potentially life-threatening condition that requires pulmonary intervention.
Which airway would be the most appropriate for a patient requiring intubation longer than 21 days? a. Oropharyngeal airway b. Esophageal obturator airway c. Tracheostomy tube d. Endotracheal intubation
ANS: C Although no ideal time to perform the procedure has been identified, it is commonly accepted that if a patient has been intubated or is anticipated to be intubated for longer than 7 to 10 days, a tracheostomy should be performed.
What nursing intervention can minimize the complications of suctioning? a. Inserting the suction catheter no more than 5 inches b. Premedicating the patient with atropine c. Hyperoxygenating the patient with 100% oxygen d. Increasing the suction to 150 mm Hg
ANS: C Hypoxemia can be minimized by giving the patient three hyperoxygenation breaths (breaths at 100% FiO2) with the ventilator before the procedure and again after each pass of the suction catheter.
Which cause of hypoxemia is the result of blood passing through unventilated portions of the lungs? a. Alveolar hypoventilation b. Dead space ventilation c. Intrapulmonary shunting d. Physiologic shunting
ANS: C Hypoxemia is the result of impaired gas exchange and is the hallmark of acute respiratory failure. Hypercapnia may be present, depending on the underlying cause of the problem. The main causes of hypoxemia are alveolar hypoventilation, ventilation-perfusion (V/Q) mismatching, and intrapulmonary shunting. Intrapulmonary shunting occurs when blood passes through a portion of a lung that is not ventilated. Physiologic shunting is normal and not a cause of hypoxemia.
What assessment technique uses the creation of sound waves across the body surface to determine abnormal densities? a. Inspection b. Palpation c. Percussion d. Auscultation.
ANS: C Percussion is the process of creating sound waves on the surface of the body to determine abnormal density of any underlying areas. Palpation is the process of touching the patient to judge the size, shape, texture, and temperature of the body surface or underlying structures. Inspection is the process of looking intently at the patient. Auscultation is the process of concentrated listening with a stethoscope to determine characteristics of body functions.
A patient presents with chest trauma from a motor vehicle accident. Upon assessment, the nurse documents that the patient is complaining of dyspnea, shortness of breath, tachypnea, and tracheal deviation to the right. In addition, the patient's tongue is blue-gray. Based on this assessment data, what additional assessment findings would the nurse expect to find? a. Kussmaul breathing pattern b. Absent breath sounds in the right lower lung fields c. Absent breath sounds in the left lung fields d. Diminished breath sounds in the right upper lung fields
ANS: C The clinical picture described is most consistent with left pneumothorax. This would cause the trachea to deviate to the right, away from the increasing pressure of the left. A pneumothorax this severe would completely collapse the left lung, thus causing absent breath sounds in that lung. The right lung fields would not be affected. Kussmaul breathing pattern is rapid, deep and labored.
A patient is admitted with community-associated pneumonia. Respirations are 32 breaths/min. Temperature is 102° F (38.6° C). Based on the readings the nurse would expect the oxyhemoglobin dissociation curve to shift. What other factors would cause the curve to shift in the same direction? a. Decreased 2,3-DPG b. Increased pH c. Increased CO2 d. Increased O2
ANS: C The oxyhemoglobin dissociation curve will shift to the right as a result of the patient's temperature. Other factors that cause the curve to shift to the right are decreased pH, increased CO2, and increased 2,3-DPG. Increased O2 will not shift the curve either right or left.
Depending on the patient's risk for the recurrence of pulmonary embolism (PE), how long may a patient remain on warfarin once they are discharged from the hospital? a. 1 to 3 months b. 3 to 6 months c. 3 to 12 months d. 12 to 36 months
ANS: C The patient should remain on warfarin for 3 to 12 months depending on his or her risk for thromboembolic disease.
Which therapeutic measure would be the most effective in treating hypoxemia in the presence of intrapulmonary shunting associated with acute respiratory distress syndrome (ARDS)? a. Sedating the patient to blunt noxious stimuli b. Increasing the FiO2 on the ventilator c. Administering positive-end expiratory pressure (PEEP) d. Restricting fluids to 500 mL per shift
ANS: C The purpose of using positive-end expiratory pressure (PEEP) in a patient with acute respiratory distress syndrome is to improve oxygenation while reducing FiO2 to less toxic levels. PEEP has several positive effects on the lungs, including opening collapsed alveoli, stabilizing flooded alveoli, and increasing functional residual capacity. Thus, PEEP decreases intrapulmonary shunting and increases compliance.
Based on the oxyhemoglobin dissociation curve, respiratory acidosis will have which effect? a. A shifting of the curve to the left b. Increased oxygen saturation c. Enhanced oxygen delivery at the tissue level d. Hypothermia
ANS: C When the curve is shifted to the right, as occurs in acidosis, although the saturation is lower than expected, a right shift enhances oxygen delivery at the tissue level because hemoglobin unloads more readily.
To select the correct size of an oropharyngeal airway, the nurse should ensure the airway extends from which area to which area? a. Tip of the nose to the ear lobe b. Middle of the mouth to the ear lobe c. Tip of the nose to the middle of the trachea d. Corner of the mouth to the angle of the jaw
ANS: D An oropharyngeal airway's proper size is selected by holding the airway against the side of the patient's face and ensuring that it extends from the corner of the mouth to the angle of the jaw. If the airway is improperly sized, it will occlude the airway. Nasopharyngeal airways are measured by holding the tube against the side of the patient's face and ensuring that it extends from the tip of the nose to the ear lobe.
In a patient who is hemodynamically stable, which procedure can be used to estimate the PaCO2 levels? a. PaO2/FiO2 ratio b. A-a gradient c. Residual volume (RV) d. End-tidal CO2
ANS: D Capnography is the measurement of exhaled carbon dioxide (CO2) gas; it is also known as end-tidal CO2 monitoring. Normally, alveolar and arterial CO2 concentrations are equal in the presence of normal ventilation-perfusion (V/Q) relationships. In a patient who is hemodynamically stable, the end-tidal CO2 (PetCO2) can be used to estimate the PaCO2. Normally, the PaO2/FiO2 ratio is greater than 286; the lower the value, the worse the lung function. The A-a gradient is normally less than 20 mm Hg on room air for patients younger than 61 years. This estimate of intrapulmonary shunting is the least reliable clinically, but it is used often in clinical decision making. Residual volume is the amount of air left in the lung after maximal exhalation. A normal value is 1200 to 1300 mL.
Patients with left-sided pneumonia may benefit from placing them in which position? a. Reverse Trendelenburg b. Supine c. On the left side d. On the right side
ANS: D Patients with unilateral lung disease should be positioned with the healthy lung in a dependent position. Because gravity normally facilitates preferential ventilation and perfusion to the dependent areas of the lungs, the best gas exchange would take place in the dependent areas of the lungs. Thus, the goal of positioning is to place the least affected area of the patient's lung in the most dependent position. Patients with unilateral lung disease should be positioned with the healthy lung in a dependent position.
What assessment technique involves having the patient breathe in and out slowly with an open mouth? a. Inspection b. Palpation c. Percussion d. Auscultation
ANS: D Percussion is the process of creating sound waves on the surface of the body to determine abnormal density of any underlying areas. Palpation is the process of touching the patient to judge the size, shape, texture, and temperature of the body surface or underlying structures. Inspection is the process of looking intently at the patient. Auscultation is the process of concentrated listening with a stethoscope to determine characteristics of body functions.
Supplemental oxygen administration is usually effective in treating hypoxemia related which situation? a. Physiologic shunting b. Dead space ventilation c. Alveolar hyperventilation d. Ventilation-perfusion mismatching
ANS: D Supplemental oxygen administration is effective in treating hypoxemia related to alveolar hypoventilation and ventilation-perfusion mismatching. When intrapulmonary shunting exists, supplemental oxygen alone is ineffective. In this situation, positive pressure is necessary to open collapsed alveoli and facilitate their participation in gas exchange. Positive pressure is delivered via invasive and noninvasive mechanical ventilation.
Which statement describes the major difference between tachypnea and hyperventilation? a. Tachypnea has increased rate; hyperventilation has decreased rate. b. Tachypnea has decreased rate; hyperventilation has increased rate. c. Tachypnea has increased depth; hyperventilation has decreased depth. d. Tachypnea has decreased depth; hyperventilation has increased depth.
ANS: D Tachypnea is manifested by an increase in the rate and decrease in the depth of ventilation. Hyperventilation is manifested by an increase in both the rate and depth of ventilation.
Which arterial blood gas (ABG) values would indicate a need for oxygen therapy? a. PaO2 of 80 mm Hg b. PaCO2 of 35 mm Hg c. HCO of 24 mEq d. SaO2 of 87%
ANS: D The amount of oxygen administered depends on the pathophysiologic mechanisms affecting the patient's oxygenation status. In most cases, the amount required should provide an arterial partial pressure of oxygen (PaO2) of greater than 60 mm Hg or an arterial hemoglobin saturation (SaO2) of greater than 90% during both rest and exercise.
A patient was admitted after a left pneumonectomy. The patient is receiving 40% oxygen via a simple facemask. The morning chest radiography study reveals right lower lobe pneumonia. After eating breakfast, the patient suddenly vomits and aspirates. What action should the nurse take next? a. Lavage the airway with normal saline. b. Place the patient supine in a semi-Fowler position. c. Manually ventilate the patient. d. Suction the airway.
ANS: D When aspiration is witnessed, emergency treatment should be instituted to secure the airway and minimize pulmonary damage. The patient's head should be turned to the side, and the oral cavity and upper airway should be suctioned immediately to remove the gastric contents.
Trauma to which vertebrae will cause ventilation dysfunction? a. C3 to C5 b. C5 to T3 c. T4 to T6 d. T7 to T10
ANS: A The phrenic nerve arises from the cervical plexus through the fourth cervical nerve, with secondary contributions by the third and fifth cervical nerves. For this reason and because the diaphragm does most of the work of inhalation, trauma involving levels C3 to C5 causes ventilation dysfunction.
Which nursing intervention should be used to optimize oxygenation and ventilation in the patient with acute lung failure? a. Provide adequate rest and recovery time between procedures. b. Position the patient with the good lung up. c. Suction the patient every hour. d. Avoid hyperventilating the patient.
ANS: A Providing adequate rest and recovery time between various procedures prevents desaturation and optimizes oxygenation. In acute lung failure, the goal of positioning is to place the least affected area of the patient's lung in the most dependent position. Patients with unilateral lung disease should be positioned with the healthy lung in a dependent position. Hyperventilate the patient before suctioning; suction patients as needed.
What are the most common presenting signs and symptoms associated with a pulmonary embolism (PE)? a. Tachycardia and tachypnea b. Hemoptysis and evidence of deep vein thromboses c. Apprehension and dyspnea d. Right ventricular failure and fever
ANS: A The patient with a pulmonary embolism may have any number of presenting signs and symptoms, with the most common being tachycardia and tachypnea. Additional signs and symptoms that may be present include dyspnea, apprehension, increased pulmonic component of the second heart sound (P1), fever, crackles, pleuritic chest pain, cough, evidence of deep vein thrombosis, and hemoptysis. Syncope and hemodynamic instability can occur as a result of right ventricular failure.
Which oxygen administration device can deliver oxygen concentrations of 90%? a. Nonrebreathing mask b. Nasal cannula c. Partial rebreathing mask d. Simple mask
ANS: A With an FiO2 of 55% to 70%, a nonrebreathing mask with a tight seal over the face can deliver 90% to 100% oxygen. It is used in emergencies and short-term therapy requiring moderate to high FiO2.
Which statement is correct concerning endotracheal tube cuff management? a. The cuff should be deflated every hour to minimize pressure on the trachea. b. A small leak should be heard on inspiration if the cuff has been inflated using the minimal leak technique. c. Cuff pressures should be kept between 20 to 30 mm Hg to ensure an adequate seal. d. Cuff pressure monitoring should be done once every 24 hours.
ANS: B Cuff pressures are monitored at a minimum of every shift and are maintained within 20 to 30 mm Hg because greater pressures decrease blood flow to the capillaries in the tracheal wall and lesser pressures increase the risk of aspiration. Pressures greater than 30 mm Hg (41 cm H2O) should be reported to the physician. Cuffs are not routinely deflated because this increases the risk of aspiration. The minimal leak technique is no longer recommended.
A patient was taken to surgery for a left lung resection. The patient returned to the unit 30 minutes ago. Upon completion of the assessment, the nurse notices that the chest tube has drained 150 mL of red fluid in the past 30 minutes. The nurse contacts the physician and suspects that the patient has developed what complication? a. Pulmonary edema b. Hemorrhage c. Acute lung failure d. Bronchopleural fistula
ANS: B Hemorrhage is an early, life-threatening complication that can occur after a lung resection. It can result from bronchial or intercostal artery bleeding or disruption of a suture or clip around a pulmonary vessel. Excessive chest tube drainage can signal excessive bleeding. During the immediate postoperative period, chest tube drainage should be measured every 15 minutes; this frequency should be decreased as the patient stabilizes. If chest tube loss is greater than 100 mL/h, fresh blood is noted, or a sudden increase in drainage occurs, hemorrhage should be suspected.
A patient with acute lung failure has been on a ventilator for 3 days and is being considered for weaning. The ventilator high-pressure limit alarm keeps alarming. What would cause this problem? a. A leak in the patient's endotracheal (ET) tube cuff b. A kink in the ventilator tubing c. The patient is disconnected from the ventilator d. A faulty oxygen filter
ANS: B High-pressure alarms will sound because of improper alarm setting; airway obstruction resulting from patient fighting ventilator (holding breath as ventilator delivers Vt); patient circuit collapse; kinked tubing; the endotracheal tube in the right mainstem bronchus or against the carina; cuff herniation; increased airway resistance resulting from bronchospasm, airway secretions, plugs, and coughing; water from the humidifier in the ventilator tubing; and decreased lung compliance resulting from tension pneumothorax, change in patient position, acute respiratory distress syndrome, pulmonary edema, atelectasis, pneumonia, or abdominal distention.
When assessing a patient, the use of touch to judge the character of the body surface and underlying organs is known as what technique? a. Inspection b. Palpation c. Percussion d. Auscultation
ANS: B Palpation is the process of touching the patient to judge the size, shape, texture, and temperature of the body surface or underlying structures. Inspection is the process of looking intently at the patient. Percussion is the process of creating sound waves on the surface of the body to determine abnormal density of any underlying areas. Auscultation is the process of concentrated listening with a stethoscope to determine characteristics of body functions.
What nursing interventions should be included in the nursing management of the patient receiving a neuromuscular blocking agent? a. Withholding all sedation and narcotics b. Protecting the patient from the environment c. Keeping the patient supine d. Speaking to the patient only when necessary
ANS: B Patient safety is a major concern for the patient receiving a neuromuscular blocking agent because these patients are unable to protect themselves from the environment. Special precautions should be taken to protect the patient at all times.
A patient was admitted with acute lung failure secondary to pneumonia. What is the single most important measure to prevent the spread of infection between staff and patients? a. Place the patient in respiratory isolation. b. Ensure everyone is using proper hand hygiene. c. Use personal protective equipment. d. Initiate prompt administration of antibiotics.
ANS: B Proper hand hygiene is the single most important measure available to prevent the spread of bacteria from person to person.
What chest radiography finding is consistent with a left pneumothorax? a. Flattening of the diaphragm b. Shifting of the mediastinum to the right c. Presence of a gastric air bubble d. Increased radiolucency of the left lung field
ANS: B Shifting of the mediastinal structures away from the area of involvement is a sign of a pneumothorax.
While conducting a physical assessment on a patient with chronic obstructive pulmonary disease (COPD), the nurse notes that the patient's breathing is rapid and shallow. What is this type of breathing pattern called? a. Hyperventilation b. Tachypnea c. Obstructive breathing d. Bradypnea
ANS: B Tachypnea is manifested by an increase in the rate and decrease in the depth of ventilation. Hyperventilation is manifested by an increase in both the rate and depth of ventilation. Obstructive breathing is characterized by progressively shallower breathing until the patient actively and forcefully exhales. Bradypnea is a slow respiratory rate characterized as less than 12 breaths/min in an adult.
Which diagnostic criteria is indicative of mild adult respiratory distress syndrome (ARDS)? a. Radiologic evidence of bibasilar atelectasis b. PaO2/FiO2 ratio less than or equal to 200 mm Hg c. Pulmonary artery wedge pressure greater than 18 mm Hg d. Increase in static and dynamic compliance
ANS: B The Berlin Definition of ARDS is as follows: timing—within 1 week of known clinical insult or new or worsening respiratory symptoms; chest imaging—bilateral opacities not fully explained by effusions, lobar or lung collapse, or nodules; origin of edema—respiratory failure not fully explained by cardiac failure or fluid overload; need objective assessment to exclude hydrostatic edema if no risk factor present; oxygenation—mild (200 mg Hg less than PaO2/FiO2 less than or equal to 300 mm Hg with positive end-respiratory airway pressure (PEEP) or constant positive airway pressure greater than or equal to 5 cm H2O), moderate (100 mg Hg less than PaO2/FiO2 less than or equal to 200 mm Hg with PEEP greater than or equal to 5 cm H2O), or severe (PaO2/FiO2 less than or equal to 100 mm Hg with PEEP greater than or equal to 5 cm H2O). The mortality rate for ARDS is estimated to be 34% to 58%.
A patient's pulse oximeter alarm goes off. The monitor reads 82%. What is the first action the nurse should perform? a. Prepare to intubate. b. Assess the patient's condition. c. Turn off the alarm and reapply the oximeter sensor. d. Increase O2 level to 4L/NC.
ANS: B The first nursing action would be to assess the patient to see if there is a change in his or her condition. If the patient is stable, then the nurse would turn off the alarm and reapply the oximeter sensor. The pulse oximeter cannot differentiate between normal and abnormal hemoglobin. Elevated levels of abnormal hemoglobin falsely elevate the SpO2. The ability of a pulse oximeter to detect hypoventilation is accurate only when the patient is breathing room air. Because most critically ill patients require some form of oxygen therapy, pulse oximetry is not a reliable method of detecting hypercapnia and should not be used for this purpose.
A patient presents with the following arterial blood gas (ABG) values: pH, 7.20; PaO2, 106 mm Hg; PaCO2, 35 mm Hg; and , 11 mEq/L. What is the interpretation of the patient's ABG? a. Uncompensated respiratory acidosis b. Uncompensated metabolic acidosis c. Uncompensated metabolic alkalosis d. Uncompensated respiratory alkalosis
ANS: B The pH indicates acidosis, and the is markedly decreased, indicating a metabolic disorder. Uncompensated metabolic acidosis values include a pH below 7.35, PaCO2 of 35 to 45 mm Hg, and below 22 mEq/L. Uncompensated respiratory acidosis values include a pH below 7.35, PaCO2 above 45 mm Hg, and of 22 to 26 mEq/L. Uncompensated respiratory alkalosis values include a pH above 7.45, PaCO2 below 35 mm Hg, and of 22 to 26 mEq/L. Uncompensated metabolic alkalosis values include a pH above 7.45, PaCO2 of 35 to 45 mm Hg, and above 26 mEq/L.
The patient's arterial blood gas (ABG) values on room air are PaO2, 40 mm Hg; pH, 7.10; PaCO2, 44 mm Hg; and , 16 mEq/L. What is the interpretation of the patient's ABG? a. Uncompensated respiratory acidosis b. Uncompensated metabolic acidosis c. Compensated metabolic acidosis d. Compensated respiratory acidosis
ANS: B The pH is below normal range (7.35 to7.45), so this is uncompensated acidosis. The PaCO2 normal and the is markedly low. This indicates uncompensated metabolic acidosis. Uncompensated metabolic acidosis values include a pH below 7.35, PaCO2 of 35 to 45 mm Hg, and below 22 mEq/L. Uncompensated respiratory acidosis values include a pH below 7.35, PaCO2 above 45 mm Hg, and of 22 to 26 mEq/L. Compensated metabolic acidosis values include a pH of 7.35 to 7.39, PaCO2 below 35 mm Hg, and below 22 mEq/L. Compensated respiratory acidosis values include a pH of 7.35 to 7.35, PaCO2 above 45 mm Hg, and above 26 mEq/L.
The patient's arterial blood gas (ABG) values on room air are PaO2, 70 mm Hg; pH, 7.31; PaCO2, 52 mm Hg; and , 24 mEq/L. What is the interpretation of the patient's ABG? a. Uncompensated metabolic alkalosis b. Uncompensated respiratory acidosis c. Compensated respiratory acidosis d. Compensated respiratory alkalosis
ANS: B The pH is closer to the acidic level, so the primary disorder is acidosis. Uncompensated respiratory acidosis values include a pH below 7.35, PaCO2 above 45 mm Hg, and of 22 to 26 mEq/L. Compensated respiratory acidosis values include a pH of 7.35 to 7.39, PaCO2 greater than 45 mm Hg, and greater than 26 mEq/L. Compensated respiratory alkalosis values include a pH of 7.41 to 7.45, PaCO2 below 35 mm Hg, and below 22 mEq/L. Uncompensated metabolic alkalosis values include a pH above 7.45, PaCO2 of 35 to 45 mm Hg, and above 26 mEq/L.
Which arterial blood gas (ABG) values represent uncompensated metabolic acidosis? a. pH, 7.29; PaCO2, 57 mm Hg; , 22 mEq/L b. pH, 7.36; PaCO2, 33 mm Hg; , 18 mEq/L c. pH, 7.22; PaCO2, 42 mm Hg; , 18 mEq/L d. pH, 7.52; PaCO2, 38 mm Hg; , 29 mEq/L
ANS: C A pH of 7.22 is below normal, reflecting acidosis. The metabolic component ( ) is low, indicating that the acidosis is metabolic in origin. Uncompensated metabolic acidosis values include a pH below 7.35, PaCO2 of 35 to 45 mm Hg, and below 22 mEq/L.
Which oxygen therapy device should is used in a patient requiring the delivery of a precise low FiO2? a. Simple mask b. Nasal cannula c. Air-entrainment mask d. Partial rebreathing mask
ANS: C An air-entrainment mask is used in patients requiring the delivery of a precise low FiO2. A simple mask, partial rebreathing mask, and nasal cannula are not able to provide as precise level of oxygen as an air-entrainment mask.
Use of oxygen therapy in the patient who is hypercapnic may result in which situation? a. Oxygen toxicity b. Absorption atelectasis c. Carbon dioxide retention d. Pneumothorax
ANS: C Deoxygenated hemoglobin carries more CO2 compared with oxygenated hemoglobin. Administration of oxygen increases the proportion of oxygenated hemoglobin, which causes increased release of CO2 at the lung level. Because of the risk of CO2 accumulation, all patients who are chronically hypercapnic require careful low-flow oxygen administration.
Which statement best describes the left bronchus? a. The left bronchus has a slight angle of 20 to 30 degrees from the midline. b. The two mainstem bronchi are structurally and functionally similar. c. The left bronchus is slightly narrower. d. The bronchi are the end units of the bronchial tree.
ANS: C The two mainstem bronchi are structurally different. The right bronchus is wider and angles at 20 to 30 degrees from the midline. The right mainstem bronchus is the most common site of aspiration of foreign objects. The left bronchus is slightly narrower than the right, and because of its position above the heart, the left bronchus angles directly toward the left lung at approximately 45 to 55 degrees from the midline.
Which blood gas parameter is the acid-base component that reflects kidney function? a. pH b. PaO2 c. PaCO2 d. HCO3 ̄
ANS: D The bicarbonate ( ) is the acid-base component that reflects kidney function. The bicarbonate is reduced or increased in the plasma by renal mechanisms. The normal range is 22 to 26 mEq/L. pH measures the hydrogen ion concentration of plasma. PaO2 measures partial pressure of oxygen dissolved in arterial blood plasma. PaCO2 measures the partial pressure of carbon dioxide dissolved in arterial blood plasma.
A patient was admitted to the critical care unit with acute respiratory failure. The patient has been on a ventilator for 3 days and is being considered for weaning. Which criteria would indicate that the patient is not tolerating weaning? a. A decrease in heart rate from 92 to 80 beats/min b. An SpO2 of 92% c. An increase in respiratory rate from 22 to 38 breaths/min d. Spontaneous tidal volumes of 300 to 350 mL
ANS: C Weaning intolerance indicators include (1) a decrease in level of consciousness; (2) a systolic blood pressure increased or decreased by 20 mm Hg; (3) a diastolic blood pressure greater than 100 mm Hg; (4) a heart rate increased by 20 beats/min; (5) premature ventricular contractions greater than 6/min, couplets, or runs of ventricular tachycardia; (6) changes in ST segment (usually elevation); (7) a respiratory rate greater than 30 breaths/min or less than 10 breaths/min; (8) a respiratory rate increased by 10 breaths/min; (9) a spontaneous tidal volume less than 250 mL; (10) a PaCO2 increased by 5 to 8 mm Hg or pH less than 7.30; (11) an SpO2 less than 90%; (12) use of accessory muscles of ventilation; (13) complaints of dyspnea, fatigue, or pain; (14) paradoxical chest wall motion or chest abdominal asynchrony; (15) diaphoresis; and (16) severe agitation or anxiety unrelieved with reassurance.
A patient is admitted with acute respiratory failure secondary to pneumonia. Upon auscultation, the nurse hears creaking, leathery, coarse breath sounds in the lower anterolateral chest area during inspiration and expiration. This finding is indicative of what condition? a. Emphysema b. Atelectasis c. Pulmonary fibrosis d. Pleural effusion
ANS: D A pleural friction rub is the result of irritated pleural surfaces rubbing together and is characterized by a leathery, dry, loud, coarse sound. A pleural friction rub is seen with pleural effusions or pleurisy and is not indicative of emphysema, atelectasis, or pulmonary fibrosis.
A patient is admitted with signs and symptoms of a pulmonary embolus (PE). What diagnostic test most conclusive to determine this diagnosis? a. ABG b. Bronchoscopy c. Pulmonary function test d. V/Q scan
ANS: D A ventilation-perfusion (V/Q) scan is the most conclusive test for a pulmonary embolus. Arterial blood gas (ABG) analysis tests oxygen levels in the blood, bronchoscopy is to used view the bronchi, and pulmonary function tests are used to measure lung volume.
A patient has been admitted with the diagnosis of acute respiratory distress syndrome (ARDS). Arterial blood gasses (ABGs) revealed an elevated pH and decreased PaCO2. The patient is becoming fatigued, and the practitioner orders a repeat ABG. Which set of results would be indicative of the patient's current condition? a. Elevated pH and decreased PaCO2 b. Elevated pH and elevated PaCO2 c. Decreased pH and decreased PaCO2 d. Decreased pH and elevated PaCO2
ANS: D Arterial blood gas analysis reveals a low PaO2 despite increases in supplemental oxygen administration (refractory hypoxemia). Initially, the PaCO2 is low as a result of hyperventilation, but eventually the PaCO2 increases as the patient fatigues. The pH is high initially but decreases as respiratory acidosis develops.
Which statement best describes the effects of positive-pressure ventilation on cardiac output? a. Positive-pressure ventilation increases intrathoracic pressure, which increases venous return and cardiac output. b. Positive-pressure ventilation decreases venous return, which increases preload and cardiac output. c. Positive-pressure ventilation increases venous return, which decreases preload and cardiac output. d. Positive-pressure ventilation increases intrathoracic pressure, which decreases venous return and cardiac output.
ANS: D Positive-pressure ventilation increases intrathoracic pressure, which decreases venous return to the right side of the heart. Impaired venous return decreases preload, which results in a decrease in cardiac output.
What is the preset positive pressure used to augment the patient's inspiratory effort known as? a. Positive end-expiratory pressure (PEEP) b. Continuous positive airway pressure (CPAP) c. Pressure control ventilation (PCV) d. Pressure support ventilation (PSV)
ANS: D Preset positive pressure used to augment the patient's inspiratory efforts is known as pressure support ventilation. With continuous positive airway pressure, positive pressure is applied during spontaneous breaths; the patient controls rate, inspiratory flow, and tidal volume. Positive end-expiratory pressure is positive pressure applied at the end of expiration of ventilator breaths.
Determination of oxygenation status by oxygen saturation alone is inadequate. What other value must be known? a. pH b. PaCO2 c. HCO- 3 d. Hemoglobin (Hgb)
ANS: D Proper evaluation of the oxygen saturation level is vital. For example, an SaO2 of 97% means that 97% of the available hemoglobin is bound with oxygen. The word available is essential to evaluating the SaO2 level because the hemoglobin level is not always within normal limits and oxygen can bind only with what is available.
What nursing intervention can facilitate the prevention of aspiration? a. Observing the amount given in the tube feeding b. Assessing the patient's level of consciousness c. Encouraging the patient to cough and to breathe deeply d. Positioning a patient in a semirecumbent position
ANS: D Semirecumbency has been shown to decrease the risk of aspiration and inhibit the development of hospital-associated pneumonia.
Which ABG values reflect compensation? a. pH, 7.26; PaCO2, 55 mm Hg; , 24 mEq/L b. pH, 7.30; PaCO2, 32 mm Hg; , 18 mEq/L c. pH, 7.48; PaCO2, 30 mm Hg; , 22 mEq/L d. pH, 7.38; PaCO2, 58 mm Hg; , 30 mEq/L
ANS: D The pH is within normal limits, and both the PaCO2 and the values are abnormal. Compensated respiratory acidosis values include a pH of 7.35 to 7.39, PaCO2 above 45 mm Hg, and above 26 mEq/L.
Which artery(s) have the lowest oxygen saturation? a. Aorta b. Subclavian c. Carotid d. Pulmonary
ANS: D The pulmonary artery delivers blood from the right ventricle to the lungs, where they receive oxygen from the alveoli. The aorta, subclavian artery, and carotid artery are all supplied from the left ventricle, where the oxygen concentration is highest.
A 75-kg patient is on a ventilator and may be ready for extubation. A respiratory therapist assesses the patient's rapid shallow breathing index (RSBI). Which result best suggests that the patient is ready for a spontaneous breathing trial? a. RSBI = 150 b. RSBI = 125 c. RSBI = 110 d. RSBI = 90
ANS: D The rapid, shallow breathing index (RSBI) can predict weaning success. An RSBI of less than 105 is considered predictive of weaning success. If the patient is receiving sedation, the medication is discontinued at least 1 hour before the RSBI is measured. If the patient meets criteria for weaning readiness and has an RSBI of less than 105, a spontaneous breathing trial can be performed.
