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- To evaluate the effectiveness of prescribed therapies for a patient with venti- latory failure, which diagnostic test will be most useful to the nurse? a. Chest x-rays b. Pulse oximetry c. Arterial blood gas (ABG) analysis d. Pulmonary artery pressure monitoring: ANS: C ABG analysis is most useful in this setting because ventilatory failure causes problems with CO retention, and ABGs provide information about the PaCO2 and pH. The other tests also may be done to help in assessing oxygenation or determining the cause of the patient's ventilatory failure.
- While caring for a patient who has been admitted with a pulmonary em- bolism, the nurse notes a change in the patient's oxygen saturation (SpO2) from 94% to 88%. The nurse will a. increase the oxygen flow rate. b. suction the patient's oropharynx. c. assist the patient to cough and deep breathe. d. help the patient to sit in a more upright position.: ANS: A Increasing oxygen flow rate usually will improve oxygen saturation in patients with ventilation-perfusion mismatch, as occurs with pulmonary embolism. Because the problem is with perfusion, actions that improve ventilation, such as deep-breathing and coughing, sitting upright, and suctioning, are not likely to improve oxygenation.
- A patient with respiratory failure has a respiratory rate of 8 and an SpO2 of 89%. The patient is increasingly lethargic. The nurse will anticipate assisting with a. administration of 100% oxygen by non-rebreather mask. b. endotracheal intubation and positive pressure ventilation. c. insertion of a mini-tracheostomy with frequent suctioning.
2 / 35 d. initiation of bilevel positive pressure ventilation (BiPAP).: ANS: B The patient's lethargy, low respiratory rate, and SpO2 indicate the need for mechanical ventilation with ventilator-con- trolled respiratory rate. Administration of high flow oxygen will not be helpful because the patient's respiratory rate is so low. Insertion of a mini-tracheostomy will facilitate removal of secretions, but it will not improve the patient's respiratory rate or oxygenation. BiPAP requires that the patient initiate an adequate respiratory rate to allow adequate gas exchange.
- The pulse oximetry for a patient with right lower lobe pneumonia indicates an oxygen saturation of 90%. The patient has rhonchi, a weak cough effort, and complains of fatigue. Which action is best for the nurse to take? a. Position the patient on the right side. b. Place a humidifier in the patient's room. c. Assist the patient with staged coughing. d. Schedule a 2-hour rest period for the patient.: ANS: C The patient's assessment indicates that assisted coughing is needed to help remove secretions, which will improve oxygenation. A 2-hour rest period at this time may allow the oxygen saturation to drop further. Humidification will not be helpful unless the secretions can be mobilized. Positioning on the right side may cause a further decrease in oxygen saturation because perfusion will be directed more toward the more poorly ventilated lung.
- When the nurse is caring for an obese patient with left lower lobe pneumonia, gas exchange will be best when the patient is positioned a. on the left side. b. on the right side. c. in the tripod position. d. in the high-Fowler's position.: ANS: B The patient should be positioned with the "good" lung in the dependent position to improve the match between ventilation and perfusion. The obese patient's abdomen will limit respiratory excursion when sitting in the high-Fowler's or tripod positions.
- When admitting a patient in possible respiratory failure with a high PaCO2, which assessment information will be of most
4 / 35 ditterentiating cardiogenic from noncardiogenic pulmonary edema.
- Which assessment finding by the nurse when caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP) indicates that the PEEP may need to be de- creased? a. The patient has subcutaneous emphysema. b. The patient has a sinus bradycardia with a rate of 52. c. The patient's PaO2 is 50 mm Hg and the SaO2 is 88%. d. The patient has bronchial breath sounds in both the lung fields.: ANS: A The subcutaneous emphysema indicates barotrauma caused by positive pressure ventilation and PEEP. Bradycardia, hypoxemia, and bronchial breath sounds are all concerns and will need to be addressed, but they are not indications that PEEP should be reduced.
- Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the family members of a patient with ARDS is correct? a. "PEEP will prevent fibrosis of the lung from occurring." b. "PEEP will push more air into the lungs during inhalation." c. "PEEP allows the ventilator to deliver 100% oxygen to the lungs." d. "PEEP prevents the lung air sacs from collapsing during exhalation.": ANS: D By preventing alveolar collapse during expiration, PEEP improves gas exchange and oxygenation. PEEP will not prevent the fibrotic changes that occur with ARDS, push more air into the lungs, or change the fraction of inspired oxygen (FIO2) delivered to the patient.
- When prone positioning is used in the care of a patient with acute respiratory distress syndrome (ARDS), which information obtained by the nurse indicates that the positioning is effective? a. The patient's PaO2 is 90 mm Hg, and the SaO2 is 92%. b. Endotracheal suctioning results in minimal mucous return. c. Sputum and blood cultures show no growth after 24 hours. d. The skin on the patient's back is intact and without redness.: ANS: A The purpose of prone positioning is to improve the patient's oxygenation as indicated by the PaO2 and
5 / 35 SaO2. The other information will be collected but does not indicate whether prone positioning has been ettective.
- The nurse obtains the vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature 101.2° F, blood pressure 90/56 mm Hg, pulse 92, respirations 34. Which action should the nurse take next? a. Administer the scheduled IV antibiotic. b. Give the PRN acetaminophen (Tylenol) 650 mg. c. Obtain oxygen saturation using pulse oximetry. d. Notify the health care provider of the patient's vital signs.: ANS: C The patient's increased respiratory rate in combination with the admission diagnosis of gram-negative sepsis indicates that acute respiratory distress syndrome (ARDS) may be developing. The nurse should check for hypoxemia, a hallmark of ARDS. The health care provider should be notified after further assessment of the patient. Administration of the scheduled antibiotic and administration of Tylenol also will be done, but they are not the highest priority for a patient who may be developing ARDS
- To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care for a patient who requires intubation and mechanical ventilation? a. Avoid use of positive end-expiratory pressure (PEEP). b. Suction every 2 hours. c. Elevate head of bed to 30 to 45 degrees. d. Give enteral feedings at no more than 10 mL/hr.: ANS: C Elevation of the head decreases the risk for aspiration. PEEP is frequently needed to improve oxygenation in patients receiving mechanical ventilation. Suctioning should be done only when the patient assessment indicates that it is necessary. Enteral feedings should provide adequate calories for the patient's high energy needs.
- A patient has a nursing diagnosis of ineffective airway clearance related to thick, secretions. Which action will be best for the nurse to include in the plan of care? a. Encourage use of the incentive spirometer. b. Offer the patient fluids at frequent intervals. c. Teach the patient the importance of coughing.
7 / 35 important to report to the health care provider? a. The patient has bibasilar lung crackles. b. The patient is sitting in the tripod position. c. The patient's respiratory rate has decreased from 30 to 10 breaths/min. d. The patient's pulse oximetry indicates an O2 saturation of 91%.: ANS: C A decrease in respiratory rate in a patient with respiratory distress suggests the onset of fatigue and a high risk for respiratory arrest. Therefore immediate action such as positive pressure ventilation is needed. Patients who are experiencing respiratory distress frequently sit in the tripod position because it decreases the work of breathing. Crackles in the lung bases may be the baseline for a patient with COPD. An oxygen saturation of 91% is common in patients with COPD and will provide adequate gas exchange and tissue oxygenation.
- When assessing a patient with chronic lung disease, the nurse finds a sudden onset of agitation and confusion. Which action should the nurse take first? a. Check pupil reaction to light. b. Notify the health care provider. c. Attempt to calm and reassure the patient. d. Assess oxygenation using pulse oximetry.: ANS: D Since agitation and confusion are frequently the initial indicators of hypoxemia, the nurse's initial action should be to assess oxygen saturation. The other actions also are appropriate, but assessment of oxygenation takes priority over other assessments and notification of the health care provider.
- The nurse is caring for a 22-year-old patient who came to the emergency de- partment with acute respiratory distress. Which information about the patient requires the most rapid action by the nurse? a. Respiratory rate is 32 breaths/min. b. Pattern of breathing is shallow. c. The patient's PaO2 is 45 mm Hg. d. The patient's PaCO2 is 34 mm Hg.: ANS: C The PaO2 indicates severe hypoxemia and respiratory failure. Rapid action is needed to prevent further
8 / 35 deterioration of the patient. Although the shallow breathing, rapid respiratory rate, and low PaCO2 also need to be addressed, the most urgent problem is the patient's poor oxygenation.
- The nurse is caring for a patient who was hospitalized 2 days earlier with aspiration pneumonia. Which assessment information is most important to communicate to the health care provider? a. Cough that is productive of blood-tinged sputum b. Scattered crackles throughout the posterior lung bases c. Temperature of 101.5° F (38.6° C) after 2 days of IV antibiotic therapy d. Oxygen saturation (SpO2) has dropped to 90% with administration of 100% O2 by non-rebreather mask.: ANS: D The patient's low SpO2 despite receiving a high fraction of inspired oxygen (FIO2) indicates the possibility of acute respiratory distress syndrome (ARDS). The patient's blood-tinged sputum and scattered crackles are not unusual in a patient with pneumonia, although they do require continued monitoring. The continued temperature elevation indicates a possible need to change antibiotics, but this is not as urgent a concern as the progression toward hypoxemia despite an increase in O2 flow rate.
- Which of these nursing actions included in the care of a mechanically ven- tilated patient with acute respiratory distress syndrome (ARDS) can the RN delegate to an experienced LPN/LVN working in the intensive care unit? a. Assess breath sounds b. Insert a retention catheter c. Place patient in the prone position d. Monitor pulmonary artery pressures: Which of these nursing actions included in the care of a mechanically ventilated patient with acute respiratory distress syndrome (ARDS) can the RN delegate to an experienced LPN/LVN working in the intensive care unit? a. Assess breath sounds b. Insert a retention catheter c. Place patient in the prone position d. Monitor pulmonary artery pressures ANS: B
10 / 35 learns that a patient with aspiration pneumonia who was admitted with respiratory distress has become increasingly agitated. Which action should the nurse take first? a. Give the prescribed PRN sedative drug. b. Offer reassurance and reorient the patient. c. Use pulse oximetry to check the oxygen saturation. d. Notify the health care provider about the patient's status.: ANS: C Agitation may be an early indicator of hypoxemia. The other actions may also be appropriate, depending on the findings about oxygen saturation.
- Which actions should the nurse initiate to reduce the risk for ventilator-as- sociated pneumonia (VAP) (select all that apply)? a. Obtain arterial blood gases daily. b. Provide a "sedation holiday" daily. c. Elevate the head of the bed to at least 30°. d. Give prescribed pantoprazole (Protonix). e. Provide oral care with chlorhexidine (0.12%) solution daily.: ANS: B, C, D, E All of these interventions are part of the ventilator bundle that is recommended to prevent VAP. Arterial blood gases may be done daily but are not always necessary and do not help prevent VAP.
- Acute Respiratory Failure: Occurs when gas exchanging functions are inadequate. Ex: insuflcient O2 is transferred to the blood or inadequate CO2 is removed from the lungs -A sudden decrease in PaO2 or rapid rise in PaCO2 can quicly become life threatening - ex: bronchospasm in asthma. -Gradual changes are tolerated better by the body Ex: COPD where the body can compensate.
- Hypercapnia: the presence of an abnormally high level of carbon dioxide in the circulating blood
- Arterial blood gases: ABG; Gold standard for testing respiratory function; a test done on arterial blood to determine levels of O2, CO2, and other gases present. Data should be interpreted along with physical assessment and clients baseline. Ex: COPD pts will have a higher than normal PaCO2 as their "normal" due to the air trapping
- Hypoxemic Respiratory Failure: PaO2 60mm Hg or less even with supplemental oxygen Ex: Pneumonia, Pulmonary emboli, Pulomary edema, alveoli disease, low CO conditions
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- Hypercapnic Respiratory Failure: INCREASED CO2 (greater than 45mm Hg) and DECREASED pH (less than 7.35), Telling us it's a VENTILATION problem, pt either not breathing enough or has an airtrapping diagnosis such as asthma or COPD
- Ventilation Perfusion mismatch: occurs in conditions during which either the flow of oxygen is limited in the alveoli or the circulation through the pulmonary capillary is compromised
- Shunt: occurs when blood exits the heart without having participated in gas exchange. A shunt can be viewed as an extreme ventilation perfusion mismatch. There are two types of shunts: anatomical and intrapulmonary
- anatomical shunt: a shunt (hole) in the heart which allows blood to move from one side of the heart to the other without going into the lungs
- intrapulmonary shunt: when blood flows through the pulmonary capillaries without participating in gas exchange such as when the alveoli are filled with fluid (pulmonary edema) or collapsed (atelectasis)
- diffusion limitation: process that occurs when gas exchange across the alveolar- capillary membrane is compromised by a process that thickens or destroys the membrane. Ex: pulmonary fibrosis, ARDS
- signs and symptoms of hypoxemia: Respiratory: dyspnea, tachypnea, prolonged expiration (i:e; 1:3 normal is 1:2), use of excessory muscles, decreased SpO2 (<80%), cyanosis (late) Cerebral: agitation, disorientation, delirium, restless, confusion, decreased LOC, coma (late) Cardiac: tachycardia, hypertension, skin cool clammy and diaphoretic, dysrhythmias and hypotension (late) Other: fatigue, unable to speak in full sentences
- signs and symptoms of hypercapnia: Respiratory: dyspnea, decreased respiratory rate or in- creased rapid rate with shallow respirations cerebral: morning headache, disorientation, progressive somnolence, coma (late) cardiac: dysrhythmias, hypertension, tachycardia, bounding pulse
13 / 35 and presence of fluid in alveoli. Surfactant rendered inactive, results in collapse of alveoli. Life threatening condition characterized by severe dyspnea, hypoxemia, & dittuse pulmonary edema. Causes are: trauma, SEPSIS, severe pulmonary infections, inhalation lung injuries. Keep in prone position. TPN feedings.
- ARDS treatment: 1. O2 administration
- prone position
- lateral rotation therapy
- positive pressure ventilation with PEEP
- permissive hypercapnia
- alternative modes of mechanical ventilation
- treatment of underlying cause
- hemodynamic monitoring
- medications: inotropic/vasopressor meds (dopamine, dobutamine, norepinephrine), diuretics, IV fluids, seda- tion/analgesia, neuromuscular blockade
- severe acute respiratory syndrome: SARS; acute resp infection caused by coronavirus (CoV). Spread by close contact via droplets Symptoms: fever, sore throat, rhinorhea, chills, rigors, diarrhea, HA, body aches, progressive resp changes (dry cough advances to diflculty breathing) Treatment: isolation, antiviral, corticosteriods
- remember that pulse ox has limitations: A patient can be hypoxic without being hypoxemic and pulse ox only measures the blood saturation of O2 to hemoglobin. Post-op hypoxia is typically caused by a pneumothorax or pulmonary embolism. When a patient suddenly becomes agitated, uncooperative, or behaves ditterenet from baseline suspect hypoxia
- The nurse is admitting a 45-year-old asthmatic patient in acute respiratory distress. The nurse auscultates the patient's lungs and notes cessation of the inspiratory wheezing. The patient has not yet received any medication. What should this finding most likely suggest to the nurse? A. Spontaneous resolution of the acute asthma attack B. An acute development of bilateral pleural effusions C. Airway constriction requiring intensive interventions
14 / 35 D. Overworked intercostal muscles resulting in poor air exchange: C. When the patient in respiratory distress has inspiratory wheezing, and then it ceases, it is an indication of airway obstruction. This finding requires emergency action to restore the airway. Cessation of inspiratory wheezing does not indicate spontaneous resolution of the acute asthma attack, bilateral pleural ettusion development, or overworked intercostal muscles in this asthmatic patient that is in acute respiratory distress.
- The nurse is caring for a patient who is admitted with a barbiturate overdose. The patient is comatose with BP 90/60, apical pulse 110, and respiratory rate
- Based upon the initial assessment findings, the nurse recognizes that the patient is at risk for which type of respiratory failure? A. Hypoxemic respiratory failure related to shunting of blood B. Hypoxemic respiratory failure related to diffusion limitation C. Hypercapnic respiratory failure related to alveolar hypoventilation D. Hypercapnic respiratory failure related to increased airway resistance: C. The patient's respiratory rate is decreased as a result of barbiturate overdose, which caused respiratory depression. The patient is at risk for hypercapnic respiratory failure resulting from the decreased respiratory rate and thus decreased CO2 elimination. Barbiturate overdose does not lead to shunting of blood, dittusion limitations, or increased airway resistance.
- The nurse is providing care for an older adult patient who is experiencing low partial pressure of oxygen in arterial blood (PaO2) as a result of worsening left-sided pneumonia. Which intervention should the nurse use to help the patient mobilize his secretions? A. Augmented coughing or huff coughing B. Positioning the patient side-lying on his left side C. Frequent and aggressive nasopharyngeal suctioning D. Application of noninvasive positive pressure ventilation (NIPPV): A.
16 / 35 decreased level of consciousness, or excessive secretions
- The nurse is aware of the value of using a mini-tracheostomy to facilitate suc- tioning when patients are unable to independently mobilize their secretions. For which patient is the use of a mini- trach indicated? A. A patient whose recent ischemic stroke has resulted in the loss of his gag reflex B. A patient who requires long-term mechanical ventilation as the result of a spinal cord injury C. A patient whose increased secretions are the result of community- acquired pneumonia D. A patient with a head injury who has developed aspiration pneumonia after his family insisted on spoon-feeding him: C. It is appropriate to suction a patient with pneumonia using a mini-trach if blind suctioning is inettective or diflcult. An absent or compromised gag reflex, long-term mechanical ventilation, and a history of aspiration contraindicates the use of a mini-trach.
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- the nurse should know that this patient is experiencing which physiologic mechanism of respiratory failure? A. Diffusion limitation Correct B. Intrapulmonary shunt Incorrect C. Alveolar hypoventilation D. Ventilation-perfusion mismatch: A. The patient with pulmonary fibrosis has a thickened alveolar-capillary interface that slows gas transport, and hypoxemia is more likely during exercise than at rest. Intrapulmonary shunt occurs when alveoli fill with fluid (e.g., ARDS, pneumonia). Alveolar hypoventilation occurs when there is a generalized decrease in ventilation (e.g., restrictive lung disease, CNS diseases, neuromuscular diseases). Ventilation- perfusion mismatch occurs when the amount of air does not match the amount of blood that the lung receives (e.g., COPD, pulmonary embolus).
- When caring for the patient with ARDS, the critical care nurse knows that therapy is appropriate for the patient when which goal is being met? A. pH is 7.32. B. PaO2 is greater than or equal to 60 mm Hg. C. PEEP increased to 20 cm H2O caused BP to fall to 80/40. D. No change in PaO2 when patient is turned from supine to prone position: B. The overall goal in caring for the patient with ARDS is for the PaO2 to be greater than or equal to 60mm Hg with adequate lung ventilation to maintain a normal pH of 7.35 to 7.45. PEEP is usually increased for ARDS patients, but a dramatic reduction in BP indicates a complication of decreased cardiac output. A positive occurrence is a marked improvement in PaO2 from perfusion better matching ventilation when the anterior air-filled, nonatelectatic alveoli become dependent in the prone position.
- The nurse in the cardiac care unit is caring for a patient who has developed acute respiratory failure. Which medication does the nurse know is being used to decrease this patient's pulmonary congestion and agitation?
19 / 35 D. Methylprednisolone (Solu-Medrol): A. For a patient with acute respiratory failure related to the heart, morphine is used to decrease pulmonary congestion as well as anxiety, agitation, and pain. Albuterol is used to reduce bronchospasm. Azithromycin is used for pulmonary infections. Methylprednisolone is used to reduce airway inflammation and edema.
- The nurse is caring for a 27-year-old man with multiple fractured ribs from a motor vehicle crash. Which clinical manifestation, if experienced by the patient, is an early indication that the patient is developing respiratory failure? A. Tachycardia and pursed lip breathing B. Kussmaul respirations and hypotension C. Frequent position changes and agitation D. Cyanosis and increased capillary refill time: C. A change in mental status is an early indication of respiratory failure. The brain is sensitive to variations in oxygenation, arterial carbon dioxide levels, and acid-base balance. Restlessness, confusion, agitation, and combative behavior suggest inadequate oxygen delivery to the brain.
- Arterial blood gas results are reported to the nurse for a 68- year-old patient admitted with pneumonia: pH 7.31, PaCO2 49 mm Hg, HCO3 26 mEq/L, and PaO2 52 mm Hg. What order from a physician should the nurse prioritize? A. Increase fluid intake to 2500 mL per 24 hours. B. Instruct the patient to breathe into a paper bag. C. Initiate oxygen at 2 L/min by nasal cannula. D. Perform chest physical therapy four times per day.: C. The arterial blood gas results indicate the patient is in uncompensated respiratory acidosis with moderate hypoxemia. Oxygen therapy is indicated to correct hypoxemia secondary to V/Q mismatch. Supplemental oxygen should be initiated at 1 to 3 L/min by nasal cannula, or 24% to 32% by simple face mask or Venturi mask to improve the PaO2. Breathing into a paper bag is indicated for hyperventilation to correct
20 / 35 respiratory alkalosis. Hydration is indicated for thick secretions, and chest physical therapy is indicated for patients with 30 mL or more of sputum production per day.
- A 72-year-old woman with aspiration pneumonia develops severe respira- tory distress. Which diagnostic finding would indicate to the nurse that the
