Sole Ch 15
The nurse is caring for a patient who is being turned prone as part of treatment for acute respiratory distress syndrome. The nurse understands that the priority nursing concern for this patient is which of the following? a) Management and protection of the airway b) Prevention of gastric aspiration c) Prevention of skin breakdown and nerve damage d) Psychological support to patient and family
A All are important, but protection of the airway is the most important intervention if the patient is placed in the prone position.
The etiology of noncardiogenic pulmonary edema in acute respiratory distress syndrome (ARDS) is related to damage to the a) alveolar-capillary membrane b) left ventricle c) mainstem bronchus d) trachea
A Damage to the alveolar-capillary membrane results in noncardiogenic pulmonary edema.
Which of the following are physiological effects of positive end-expiratory pressure (PEEP) used in the treatment of ARDS? (Select all that apply.) a) Increases functional residual capacity b) Prevents collapse of unstable alveoli c) Improves arterial oxygenation d) Opens collapsed alveoli e) Improves carbon dioxide retention
A, B, C, D Ventilatory support for ARDS typically includes PEEP to restore functional residual capacity, open collapsed alveoli, prevent collapse of unstable alveoli, and improve arterial oxygenation. PEEP does not improve CO2 retention.
The nurse is caring for a mechanically ventilated patient. The nurse understands that strategies to prevent ventilator-associated pneumonia include which of the following? (Select all that apply.) a) Drain condensate from the ventilator tubing away from the patient b) Elevate HOB 30 to 45 degrees c) Instill normal saline as part of the suctioning procedure d) Perform regular oral care with chlorhexidine e) Awaken the patient daily to determine need for continued ventilation
A, B, D Condensate should be drained away from the patient to avoid drainage back into the patient's airway. Prevention guidelines recommend elevating the head of bed at 30 to 45 degrees. Regular antiseptic oral care, with an agent such as chlorhexidine, reduces oropharyngeal colonization. Daily "sedation holidays" help determine the need to continue mechanical ventilation. Normal saline is not recommended as part of the suctioning procedure, and it may increase the risk for infection.
Identify diagnostic criteria for ARDS. (Select all that apply.) a) Bilateral infiltrates on chest x-ray study b) Decreased cardiac output c) PaO2/ FiO2 ratio of less than 200 c) Pulmonary artery occlusion pressure (PAOP) of more than 18 mm Hg d) PAOP less than 18 mm Hg
A, C Diagnostic criteria for ARDS include bilateral infiltrates, or "white out," on chest x-ray study and a low PaO2/FiO2 ratio.
The nurse calculates the PaO2/FiO2 ratio for the following values: PaO2 is 78 mm Hg; FiO2 is 0.6 (60%). a) 46.8; meets criteria for ARDS b) 130; meets criteria for ARDS c) 468; normal lung function d) Not enough data to compute the ratio
B 78/0.60 = 130, which meets the criteria for ARDS.
Which of the following statements is true regarding venous thromboembolism (VTE) and pulmonary embolus (PE)? a) PE should be suspected in any patient who has unexplained cardiorespiratory complaints and risk factors for VTE b) Bradycardia and hyperventilation are classic symptoms of PE c) Dyspnea, chest pain, and hemoptysis occur in nearly all patients with PE d) Most critically ill patients are at low risk for VTE and PE and do not require prophylaxis
A PE should be suspected in any patient who has unexplained cardiorespiratory complaints and risk factors for VTE. Dyspnea, hemoptysis, and chest pain have been called the "classic" signs and symptoms for PE, but the three signs and symptoms actually occur in less than 20% of cases.
The patient with acute respiratory distress syndrome (ARDS) would exhibit which of the following symptoms? a) Decreasing PaO2 levels despite increased FiO2 administration b) Elevated alveolar surfactant levels c) Increased lung compliance with increased FiO2 administration d) Respiratory acidosis associated with hyperventilation
A Patients with ARDS often have hypoxemia refractory to treatment. Surfactant levels are often diminished in ARDS. Compliance decreases in ARDS. In early ARDS,hyperventilation may occur along with respiratory alkalosis.
During rounds, the provider alerts the team that proning is being considered for a patient with acute respiratory distress syndrome. The nurse understands that proning is a) an optional treatment to improve ventilation b) less of a risk for skin breakdown because the patient is face down c) possible with minimal help from coworkers d) used to provide continuous lateral rotational turning
A Proning is considered to improve ventilation by shifting perfusion from the posterior bases of the lung to the anterior portion. The patient is not responding to treatment, and all options should be considered.
Select the strategies for preventing deep vein thrombosis (DVT) and pulmonary embolus (PE). (Select all that apply.) a) Graduated compression stockings b) Heparin or low-molecular weight heparin for patients at risk c) SCDs d) Strict bed rest e) Leg massage
A, B, C Graduated compression stockings, sequential compression devices, and anticoagulation can reduce the risk for DVT. Physical activity can also reduce the risk; bed rest increases the risk. Leg massage is not recommended.
The nurse is caring for a patient in acute respiratory failure and understands that the patient should be positioned (Select all that apply.) a) high Fowler's b) side lying with HOB elevated c) sitting in a chair d) supine w/ bed flat e) Trendelenburg
A, B, C Patients in respiratory distress are unable to tolerate a flat position. Trendelenburg would also be contraindicated as the weight of the organs on the lungs would inhibit movement. High Fowler's is appropriate. Side lying with head of bed elevated, sitting in a chair, and high Fowler's position are all appropriate ways to position the patient to facilitate gas exchange and comfort.
Which of the following are components of the Institute for Healthcare Improvement's (IHI's) ventilator bundle? (Select all that apply.) a) Interrupt sedation each day to assess readiness to extubate b) Maintain head of bed at least 30 degrees of elevation c) Provide deep vein thrombosis prophylaxis d) Provide prophylaxis for peptic ulcer disease e) Swab the mouth with foam swabs every 2 hours
A, B, C, D Options A, B, C, and D are components of the IHI ventilator bundle. Oral care with chlorhexidine has recently been added to the IHI bundle. Swabbing alone provides comfort care.
The nurse is caring for a patient with cystic fibrosis (CF) and understands that treatment consists of which of the following? (Select all that apply.) a) Airway clearance therapies b) Antibiotic therpy c) Nutritional support d) Tracheostomy e) Lung transplant
A, B, C, E The three cornerstones of care for a patient with CF are antibiotic therapy, airway clearance, and nutritional support. Lung transplant is a treatment modality for those who can get a match and who do not have current respiratory failure. A tracheostomy is not a standard treatment for CF.
The nurse is assessing a patient with acute respiratory distress syndrome. An expected assessment is a) cardiac output of 10 L/min and low systemic vascular resistance b) PAOP of 10 mm Hg and PaO2 of 55 c) PAOP of 20 mm Hg and cardiac output of 3 L/min d) PAOP of 5 mm Hg and high systemic vascular resistance
B A normal PAOP with hypoxemia is an expected assessment finding in ARDS although this has been deleted from the most current definition. Cardiac output of 10 L/min and low systemic vascular resistance are expected findings in sepsis. PAOP of 20 mm Hg and cardiac output of 3 L/min are expected findings in heart failure. PAOP of 5 mm Hg and high systemic vascular resistance are expected findings in hypovolemic shock.
The nurse is caring for a postoperative patient with chronic obstructive pulmonary disease (COPD). Which assessment would be a cue to the patient developing postoperative pneumonia? a) Bradycardia b) Change in sputum characteristics c) Hypoventilation and respiratory acidosis d) Pursed-lip breathing
B Change in the character of sputum may signal the development of a respiratory infection in the patient with COPD.
A patient at high risk for pulmonary embolism is receiving enoxaparin. The nurse explains to the patient: a) "I'm going to contact the pharmacist to see if you can take this medication by mouth." b) "This injection is being given to prevent blood clots from forming." c) "This medication will dissolve any blood clots you might get." d) "You should not be receiving this medication. I will contact the provider to get it stopped."
B Enoxaparin, or low-molecular weight heparin, is recommended for patients at high risk for PE. This patient is at high risk and the medication is indicated. It is given subcutaneously, not by mouth. The drug prevents clots from forming but does not dissolve them.
When fluid is present in the alveoli, a) alveoli collapse and atelectasis occurs b) diffusion of oxygen and carbon dioxide is impaired c) hypoventilation occurs d) the patient is in heart failure
B Fluid prevents the diffusion of gases
The nurse assesses a patient who is admitted for an overdose of sedatives. The nurse expects to find which acid-base alteration? a) Hyperventilation and respiratory acidosis b) Hypoventilation and respiratory acidosis c) Hypoventilation and respiratory alkalosis d) Respiratory acidosis and normal oxygen levels
B Hypoventilation is common after overdose and results in impaired elimination of carbon dioxide and respiratory acidosis. The overdose depresses the respiratory drive, which results in hypoventilation, not hyperventilation. Hypoxemia is expected secondary to depressed respirations
The nurse is assessing a patient. Which assessment would cue the nurse to the potential of acute respiratory distress syndrome (ARDS)? a) Increased oxygen saturation via pulse oximetry b) Increased peak inspiratory pressure on the ventilator c) Normal chest radiograph with enlarged cardiac structures d) PaO2/FiO2 ratio >300
B Increased peak inspiratory pressures are often early indicators of ARDS. Oxygen saturation decreases in ARDS. Chest x-ray study will show progressive infiltrates. In ARDS, a PaO2/FiO2 ratio of less than 200 is a criterion.
An acute exacerbation of asthma is treated with which of the following? a) Corticosteroids and theophylline by mouth b) Inhaled bronchodilators and intravenous corticosteroids c) Prone positioning or continuous lateral rotation d) Sedation and inhaled bronchodilators
B Inhaled bronchodilators and intravenous corticosteroids are standard treatment for the exacerbation of asthma; they promote dilation of the bronchioles and decreased inflammation of the airways.
The nurse is discharging a patient home following treatment for community-acquired pneumonia. As part of the discharge teaching, the nurse instructs, a) "If you get the pneumococcal vaccine, you'll never get pneumonia again." b) "It is important for you to get an annual influenza shot to reduce your risk of pneumonia." c) "Stay away from cold, drafty places because that increases your risk of pneumonia when you get home." d) "Since you have been treated for pneumonia, you now have immunity from getting it in the future."
B The influenza vaccine reduces the risk of pneumonia by more than 50%.
The nurse is caring for a patient with a diagnosis of pulmonary embolism. The nurse understands that the most common cause of a pulmonary embolus is a) amniotic fluid embolus b) deep vein thrombosis from lower extremities c) fat embolus from a long bone fracture d) vegetation that dislodges from an infected CVC
B The most common cause of a pulmonary embolus is deep vein thrombosis. The other responses are less common causes.
Which of the following statements is true regarding oral care for the prevention of ventilator-associated pneumonia (VAP)? (Select all that apply.) a) Tooth brushing is performed every 2 hours for the greatest effect b) Implementing a comprehensive oral care program is an intervention for preventing VAP c) Oral care protocols should include oral suctioning and brushing teeth d) Protocols that include chlorhexidine gluconate have been effective in preventing VAP e) Using oral swabs or toothettes are just as effective as brushing the teeth
B, C, D A comprehensive oral care protocol is an intervention for preventing VAP. It includes oral suction, brushing teeth every 12 hours, and swabbing. Chlorhexidine gluconate has been effective in patients who have undergone cardiac surgery. Actual toothbrushing is vital to the VAP bundle.
A strategy for preventing pulmonary embolism in patients at risk who cannot take anticoagulants is a) administration of two aspirin tablets every 4 hours b) infusion of thrombolytics c) insertion of a vena cava filter d) SQ heparin administration every 2 hours
C A filter may be inserted as a prevention measure in patients who are at high risk for pulmonary embolism.
The basic underlying pathophysiology of acute respiratory distress syndrome results in a) a decrease in the number of white blood cells available b) damage to the right mainstem bronchus c) damage to the type II pneumocytes, which produce surfactant d) decreased capillary permeability
C Acute respiratory distress syndrome results in damage to the pneumocytes, increased capillary permeability, and noncardiogenic pulmonary edema.
Which of the following acid-base disturbances commonly occurs with the hyperventilation and impaired gas exchange seen in severe exacerbation of asthma? a) Metabolic acidosis b) Metabolic alkalosis c) Respiratory acidosis d) Respiratory alkalosis
C Although the patient with a severe exacerbation of asthma hyperventilates, gas exchange is impaired, which causes respiratory acidosis.
The nurse is discharging a patient with asthma. As part of the discharge instruction, the nurse instructs the patient to prevent exacerbation by: a) obtaining an appointment for follow-up pulmonary function studies 1 week after discharge b) limiting activity until the patient is able to climb two flights of stairs c) taking all asthma medications as prescribed d) taking medications on a "prn" basis according to symptoms
C Exacerbation of asthma is often related to not adhering to the therapeutic regimen; patient teaching is essential.
A patient presents to the emergency department in acute respiratory failure secondary to community-acquired pneumonia. The patient has a history of chronic obstructive pulmonary disease. The nurse anticipates which treatment to facilitate ventilation? a) Emergency tracheostomy and mechanical ventilation b) Mechanical ventilation via an endotracheal tube c) Noninvasive positive-pressure ventilation (NPPV) d) Oxygen at 100% via bag-valve-mask device
C Noninvasive measures are often recommended in the initial treatment of the patient with chronic obstructive pulmonary disease to prevent intubation and ventilator dependence. The history of chronic obstructive pulmonary disease increases the risk for ventilator dependence, so noninvasive options are a priority.
The nurse is caring for a patient with acute respiratory distress syndrome who is hypoxemic despite mechanical ventilation. The provider prescribes a nontraditional ventilator mode as part of treatment. Despite sedation and analgesia, the patient remains restless and appears to be in discomfort. The nurse informs the provider of this assessment and anticipates an order for a) continuous lateral rotation therapy b) guided imagery c) neuromuscular blockade d) prone positioning
C Paralysis and additional sedation may be needed if the patient requires nontraditional ventilation.
Intrapulmonary shunting refers to a) alveoli that are not perfused b) blood that is shunted from the left side of the heart to the right and causes heart failure c) blood that is shunted from the right side of the heart to the left without oxygenation d) shunting of blood supply to only one lung
C Shunting refers to blood that is not oxygenated in the lungs.
A definitive diagnosis of pulmonary embolism can be made by a) ABG analysis b) chest x-ray examination c) pulmonary angiogram d) ventilation-perfusion scanning
C The angiogram is one test that can confirm pulmonary embolism.
In assessing a patient, the nurse understands that an early sign of hypoxemia is a) clubbing of nail beds b) cyanosis c) hypotension d) restlessness
D Central nervous system signs, such as restlessness, are early indications of low oxygen levels.
The nurse is concerned that a patient is at increased risk of developing a pulmonary embolus and develops a plan of care for prevention to include which of the following? a) Antiseptic oral care b) Bed rest with HOB elvated c) Coughing and deep breathing d) Mobility
D Mobility helps to prevent deep vein thrombosis and pulmonary embolus.
The nurse is caring for a patient with acute respiratory failure and identifies "Risk for Ineffective Airway Clearance" as a nursing diagnosis. A nursing intervention relevant to this diagnosis is to a) elevate the HOB 30 degrees b) obtain an order for VTE prophylaxis c) provide adequate sedation d) reposition the patient q2h
D Repositioning the patient will facilitate mobilization of secretions.
Which of the following treatments may be used to dissolve a thrombus that is lodged in the pulmonary artery? a) Aspirin b) Embolectomy c) Heparin d) Thrombolytics
D Thrombolytics are useful in the management of pulmonary embolus and are given to dissolve the clot.
