Exam 1 Tryhard 220 Flashcards
You’re providing care to a patient who is being treated for aspiration pneumonia. The patient is on a 100% non-rebreather mask. Which finding below is a HALLMARK sign and symptom that the patient is developing acute respiratory distress syndrome (ARDS)?
A. The patient is experiencing bradypnea.
B. The patient is tired and confused.
C. The patient’s PaO2 remains at 45 mmHg.
D. The patient’s blood pressure is 180/96.
C. The patient’s PaO2 remains at 45 mmHg.
A hallmark sign and symptom found in ARDS is refractory hypoxemia. This is where that although the patient is receiving a high amount of oxygen (here a 100% non-rebreather mask) the patient is STILL hypoxic. Option C is the answer because it states the patient’s arterial oxygen level is remaining at 45 mmHg (a normal is 80 mmHg but when treating patients with ARDS a goal is at least 60 mmHg). Yes, the patient can be tired and confused from a low oxygen level BUT this question wants to know the HALLMARK sign and symptom.
During the exudative phase of acute respiratory distress syndrome (ARDS), the patient’s lung cells that produce surfactant have become damaged. As the nurse you know this will lead to?
A. bronchoconstriction
B. atelectasis
C. upper airway blockage
D. pulmonary edema
B. atelectasis
Surfactant decreases surface tension in the lungs. Therefore, the alveoli sacs will stay stable when a person exhales (hence the sac won’t collapse). If there is a decrease in surfactant production this creates an unpredictable alveoli sac that can easily collapse, hence a condition called ATELETASIS will occur (collapse of the lung tissue) when there is a decrease production in surfactant.
A patient has been hospitalized in the ICU for a near drowning event. The patient’s respiratory function has been deteriorating over the last 24 hours. The physician suspects acute respiratory distress syndrome. A STAT chest x-ray is ordered. What finding on the chest x-ray is indicative of ARDS?
A. infiltrates only on the upper lobes
B. enlargement of the heart with bilateral lower lobe infiltrates
C. white-out infiltrates bilaterally
D. normal chest x-ray
C. white-out infiltrates bilaterally
You’re providing care to a patient who was just transferred to your unit for the treatment of ARDS. The patient is in the exudative phase. The patient is ordered arterial blood gases. The results are back. Which results are expected during this early phase of acute respiratory distress syndrome that correlates with this diagnosis?
A. PaO2 40, pH 7.59, PaCO2 30, HCO3 23
B. PaO2 85, pH 7.42, PaCO2 37, HCO3 26
C. PaO2 50, pH 7.20, PaCO2 48, HCO3 29
D. PaO2 55, pH 7.26, PaCO2 58, HCO3 19
A. PaO2 40, pH 7.59, PaCO2 30, HCO3 23
This option demonstrates respiratory alkalosis. In the early stages of ARDS (exudative) the patient will start to enter in respiratory alkalosis. The patient starts to have tachypnea (the body’s way of trying to increase the oxygen level but it can’t). They will have a very low PaO2 level (normal PaO2 is 80 mmHg), the blood pH will become high (normal is 7.35-7.45) (alkalotic). In the late stage, the patient can enter into respiratory acidosis.
Which patient below is at MOST risk for developing ARDS and has the worst prognosis?
A. A 52-year-old male patient with a pneumothorax.
B. A 48-year-old male being treated for diabetic ketoacidosis.
C. A 69-year-old female with sepsis caused by a gram-negative bacterial infection.
D. A 30-year-old female with cystic fibrosis.
C. A 69-year-old female with sepsis caused by a gram-negative bacterial infection.
Sepsis is the MOST common cause of ARDS because of systemic inflammation experienced. This is also true if the cause of the sepsis is a gram-negative bacterium (this also makes the infection harder to treat…hence poor prognosis). With sepsis, the immune cells that are present with the inflammation travel to the lungs and damage the alveolar capillary membrane leading to fluid to leak in the alveolar sacs.
As the nurse you know that acute respiratory distress syndrome (ARDS) can be caused by direct or indirect lung injury. Select below all the INDIRECT causes of ARDS:
A. Drowning B. Aspiration C. Sepsis D. Blood transfusion E. Pneumonia F. Pancreatitis
C. Sepsis
D. Blood transfusion
F. Pancreatitis
Indirect causes are processes that can cause inflammation OUTSIDE of the lungs….so the issue arises somewhere outside the lungs. Therefore, sepsis (infection…as long as it is outside the lungs), blood transfusion, and pancreatitis are INDIRECT causes. Drowning, aspiration, and pneumonia are issues that arise in the lungs (therefore, they are DIRECT causes of lung injury).
A patient is on mechanical ventilation with PEEP (positive end-expiratory pressure). Which finding below indicates the patient is developing a complication related to their therapy and requires immediate treatment?
A. HCO3 26 mmHg
B. Blood pressure 70/45
C. PaO2 80 mmHg
D. PaCO2 38 mmHg
B. Blood pressure 70/45
Mechanical ventilation with PEEP can cause issues with intrathoracic pressure and decrease the cardiac output (watch out for a low blood pressure) along with hyperinflation of the lungs (possible pneumothorax or subq emphysema which is air that escapes into the skin because the lungs are leaking air).
You are caring for a patient with acute respiratory distress syndrome. As the nurse you know that prone positioning can be beneficial for some patients with this condition. Which findings below indicate this type of positioning was beneficial for your patient with ARDS?
A. Improvement in lung sounds
B. Development of a V/Q mismatch
C. PaO2 increased from 59 mmHg to 82 mmHg
D. PEEP needs to be titrated to 15 mmHg of water
A. Improvement in lung sounds
C. PaO2 increased from 59 mmHg to 82 mmHg
Prone positioning helps improve PaO2 (82 mmHg is a good finding) without actually giving the patient high concentrations of oxygen. It helps improves perfusion and ventilation (hence correcting the V/Q mismatch). In this position, the heart is no longer laying against the posterior part of the lungs (improves air flow…hence improvement of lung sounds) and it helps move secretions from other areas that were fluid filled and couldn’t move in the supine position, hence helping improve atelectasis.
A nurse must position the patient prone after his diagnosis of acute respiratory distress syndrome (ARDS). Which of the following is a benefit of using this position? Select all that apply.
A.Decreased atelectasis
B.Reduced need for endotracheal intubation
C.Mobilization of secretions
D.Decreased pleural pressure
E.Increased response to corticosteroid therapy
A.decreased atelectasis
C.mobilization of secretions
D. decreased pleural pressure
Decreased atelectasis”, “Mobilization of secretions” and “Decreased pleural pressure” are correct. Prone positioning, or placing the patient face down with the head turned to the side, helps with pulmonary function in the patient diagnosed with ARDS. When the patient is placed in prone position, the heart and diaphragm are not pressing against the lungs, which means that pleural pressure is reduced. When there is less pressure exerted on the lungs, atelectasis decreases. Studies have shown that many patients in the prone position have increased lung secretions, which improves oxygenation.
A nurse walks in to a client who is in respiratory distress. The client has tracheal deviation to the right side. The nurse knows to prepare for which of the following emergent procedures?
A.Chest tube insertion on the left side.
B.Chest tube insertion on the right side.
C.Intubation
D.Tracheostomy
A. chest tube insertion on left side
Tracheal deviation indicates a pneumothorax, the direction of the deviation indicates the side the pneumothorax is on. If the trachea is deviating to the right, then the pneumo is on the left. The treatment for this is a chest tube on the side of trhe deflated lung.
A nurse is caring for a patient with ARDS. Which of the following clinical indicators would signify that this client is in respiratory failure? Select all that apply.
A.Pulse oximetry of 94% on room air b.A PaO2 level below 60 mmHg C.An ABG pH level of 7.35 D.A pCO2 level over 50 mmHg E.A respiratory rate of over 16/minute
B.PaO2 below 60
D.PCO2 over 50
respiratory diseases can cause such compromise that the patient will suffer symptoms; however, there are certain clinical indicators that can clarify whether the patient is actually in respiratory failure. Clinical indicators of respiratory failure include pulse oximetry of less than 91% on room air, PaO2 level less than 60 mmHg, and a pCO2 level of over 50 mmHg.
A patient who has recovered from ARDS in the ICU is now malnourished and has lost a significant amount of weight. The physician orders TPN to add nutrition for the patient, who then develops re-feeding syndrome. Which of the following signs or symptoms would the nurse expect to see with re-feeding syndrome? Select all that apply.
A.Impaired mental status B.Insulin resistance C.Seizures D.Persistent weight loss E.Constipation
A.impaired mental status
B.insulin resistance
C.seizures
“Impaired mental status”, “Insulin resistance” and “Seizures” are correct. Re-feeding syndrome can occur as a response to nutrient reintroduction after a period of starvation. When an extremely malnourished patient receives TPN, the body has to adjust to receiving nutrients again, which can cause shifts in electrolytes in the body. These shifts in electrolytes can result in sudden and often fatal complications. Signs and symptoms of re-feeding syndrome include confusion and impaired mental status, insulin resistance, seizures, coma and death.
A 25-year-old patient in the ICU is being treated for acute respiratory distress syndrome (ARDS). The patient is on a ventilator and requires 80 percent FiO2. Which information would the nurse most likely need to report about the patient to the respiratory therapist working with her?
A.The patient needs an arterial blood gas drawn
B.The patient needs endotracheal suctioning
C.The patient needs more oxygen because of his saturations
D.The patient needs a hemoglobin level drawn
A.The patient needs an arterial blood gas drawn
Respiratory therapists have many duties in the healthcare facility and they frequently monitor and work out many technical details of the patients care when a ventilator is being used. A respiratory therapist would most likely change the ventilator settings but the nurse is able to increase the oxygen level on the ventilator and the nurse can suction the patient. It is often part of the job description for a respiratory therapist to draw arterial blood gas levels.
The nurse is caring for a client with suspected acute respiratory distress syndrome (ARDS). Which symptom of ARDS should the nurse anticipate will appear within 24 to 48 hours after the initial insult? (Select all that apply.)
A.Shortness of breath B.Rapid breathing C.Fluid imbalance D.Chest x-ray clear of infiltrates E.Arterial blood gases varying from normal limits
A.Shortness of breath
B.Rapid breathing
D.Chest x-ray clear of infiltrates
Rapid breathing and shortness of breath are two early symptoms of ARDS that manifest in the first day or two after the initial injury. On chest x-ray, no infiltrates will be noted in the early stages and lung sounds will be clear. Fluid imbalance and abnormal arterial blood gas levels will be noted later in the disease process.
A client is diagnosed with acute respiratory distress syndrome (ARDS). The client’s spouse asks the nurse what caused ARDS. Which etiology of indirect injury to the lungs should the nurse include in the response? (Select all that apply.)
A.Smoke inhalation B.Systemic sepsis C.Fat embolism D.Multiple blood transfusions E.Pancreatitis
B.Systemic sepsis
D.Multiple blood transfusions
E.Pancreatitis
Pancreatitis, systemic sepsis, and multiple blood transfusions are causes of indirect injury to the lungs. Smoke inhalation and fat embolisms are causes of direct injury to the lungs.
The nurse is caring for a client who had an episode of near-drowning 5 days ago. This morning, the nurse noted rhonchi in the lower lung lobes on auscultation. Which action by the nurse is best?
A.Documenting the findings as normal
B.Preparing for intubation
C.Notifying the healthcare provider
D.Monitoring vital signs and oxygen saturation every 2 hours
C.Notifying the healthcare provider
Changes in lung sounds after a pulmonary injury, like near-drowning, can indicate that the client is developing acute respiratory distress syndrome (ARDS). The nurse should notify the healthcare provider of the change in the client’s condition. Intubation is not necessary unless the client is in respiratory distress. Rhonchi on auscultation are not a normal finding and require the nurse to take action. It is not appropriate for the nurse to simply monitor the client without taking action to prevent a worsening of the client’s condition.
The nurse is caring for a client with respiratory acidosis secondary to end-stage acute respiratory distress syndrome (ARDS). Which result should the nurse anticipate on the arterial blood gas?
A.High PaO2 and low PaCO2
B.Low PaO2 and low PaCO2
C.Low PaO2 and high PaCO2
D.High PaO2 and high PaCO2
C. Low PaO2 and high PaCO2
In end-stage ARDS, physiological changes in the alveoli prevent CO2 from diffusing across the alveolar membranes, causing the PaCO2 to rise and PaO2 to fall. Eventually, respiratory distress and respiratory failure will develop, and without further intervention, death will result.
A client who is diagnosed with acute respiratory distress syndrome (ARDS) requires mechanical ventilation. Which ventilator mode should the nurse expect to implement to promote pressure throughout the respiratory cycle?
A.Sensitivity
B.Positive end-expiratory pressure (PEEP)
C.Flow rate
D.Tidal volume (TV)
Positive end-expiratory pressure (PEEP)
Positive end-expiratory pressure can be used with many different ventilator settings and maintains positive pressure in between breaths and during exhalation, preventing collapse of the alveoli. Flow rate, sensitivity, and tidal volume are settings that can be adjusted on the ventilator.
The nurse is caring for a client with acute respiratory distress syndrome (ARDS) who needs an artificial airway to assist in maintaining an open airway. Which airway will the nurse plan to reposition every 8 hours while providing care?
A.Endotracheal
B.Nasopharyngeal
C.Oropharyngeal
D.Tracheostomy
B. Nasopharyngeal
The nasopharyngeal airway must be repositioned every 8 hours to prevent necrosis of the mucosa. The other airways will not require this intervention from the nurse.
During assessment of a client with acute respiratory distress syndrome (ARDS), the nurse notes an oxygen saturation of 78% and a respiratory rate of 28 breaths/min. The nurse notifies the healthcare provider and should prepare for intubation using which type of airway?
A.Tracheostomy
B.Endotracheal tube
C.Oropharyngeal airway
D.Nasopharyngeal airway
B.Endotracheal tube
An endotracheal tube is the most common type of airway placed, especially in emergency situations in which mechanical ventilation is required. This client would not initially need a tracheostomy, because it is an airway used for long-term support. Oropharyngeal and nasopharyngeal airways are only used when the upper air passages are at risk of becoming obstructed by secretions or the tongue.
The nurse is assessing an older adult client with acute respiratory distress syndrome (ARDS). Which assessment finding indicates an early sign of hypoxemia for this client? (Select all that apply.)
A.Agitation B.Tachypnea C.Confusion D.Anxiety E.Dyspnea
A.Agitation
C.Confusion
D.Anxiety
Anxiety, agitation, and confusion are assessment findings that older adult clients experience as early signs of hypoxemia. While dyspnea and tachypnea may indicate hypoxemia, these are not early symptoms the nurse will find during the assessment process.
The nurse is providing care to a client with acute respiratory distress syndrome (ARDS). Which independent intervention should the nurse prepare to perform for this client? (Select all that apply.)
A.Maintain the head of the bed at 30 degrees.
B.Recommend a prone position to facilitate oxygenation.
C.Prescribe analgesia for pain.
D.Order a Foley catheter to monitor urine output.
E.Auscultate heart and lung sounds.
A.Maintain the head of the bed at 30 degrees.
B.Recommend a prone position to facilitate oxygenation.
E.Auscultate heart and lung sounds.
The nurse can independently auscultate heart and lung sounds, maintain the head of the bed at 30 degrees, and recommend prone positioning to facilitate oxygenation. It is outside the scope of nursing practice for the nurse to prescribe analgesics for pain or order a Foley catheter to monitor urine output.
The nurse is planning care for a client with acute respiratory distress syndrome (ARDS). Which independent nursing intervention should the nurse include in the care of this client? (Select all that apply.)
A.Maintain the head of the bed at less than 30 degrees.
B.Obtain a sputum culture.
C.Prescribe surfactant therapy.
D.Position the client in a prone position for 60 minutes five times a day.
E.Suction the airway as needed.
B.Obtain a sputum culture
E.Suction the airway as needed
Nursing interventions for a client who is suffering from ARDS include suctioning and obtaining sputum cultures. It is outside the scope of nursing practice to prescribe surfactant therapy. The head of the bed should be maintained at greater than 30 degrees. Prone positioning is recommended for 30 minutes three to four times per day.
The nurse is caring for a client who is in the process of weaning off of mechanical ventilation. Which assessment finding should the nurse report to the healthcare provider? (Select all that apply.)
A.Abdominal breathing B.Oxygen saturation level of 98% C.Respiratory rate of 18 beats/min D.Pallor E.Agitation
A)Abdominal breathing
D)Pallor
E)Agitation
Assessment findings that may indicate dysfunctional weaning include pallor or cyanosis, agitation or apprehension, presence of abdominal breathing, abnormal vital signs, and decreased level of consciousness. A respiratory rate of 18 beats/min and oxygen saturation level of 98% are both within normal limits and do not need to be reported.
A firefighter who was involved in extinguishing a house fire is being treated for smoke inhalation. He develops severe hypoxia 48 hours after the incident, requiring intubation and mechanical ventilation. Which of the following conditions has he most likely developed?
A.Acute respiratory distress syndrome (ARDS).
B.Atelectasis.
C.Bronchitis.
D.Pneumonia
A.ARDS
Rationale:
Severe hypoxia after smoke inhalation typically is related to ARDS. The other choices aren’t typically associated with smoke inhalation.
A nurse is assessing a female client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse assesses for which earliest sign of acute respiratory distress syndrome?
A. Bilateral wheezing
B. Inspiratory Crackles
C. Intercostal retractions
D. Increased respiratory rate
D. Increased respiratory rate
The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles.
A male client has been admitted with chest trauma after a motor vehicle accident and has undergone subsequent intubation. A nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breathe sounds in right upper lobe of the lung. The nurse immediately assesses for other signs of:
A.Pulmonary Embolism
B.Right pneumothorax
C.Displaced endotracheal tube
D.Acute respiratory distress syndrome
B.Right pneumothorax
Rationale:
Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. Pneumothorax can cause increased airway pressure because of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds. An endotracheal tube that is inserted too far can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side because of the degree of curvature of the right and left main stem bronchi.
During the Fibrotic Phase of ARDS, ____________________ .
A. Fluids shift into the alveoli, the alveoli and bronchii collapse, and lose lung compliance
B. The lung starts to repair itself; this is where the patient starts to get better or the condition deteriorates.
C. Fibrous tissue forms and lungs don’t expand well; the effort to breathe increases O2 demand which causes more effort to breathe.
C. Fibrous tissue forms and lungs don’t expand well; the effort to breathe increases O2 demand which causes more effort to breathe.
While caring for a patient who has been admitted with a pulmonary embolism, 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.
A.Increase the oxygen flow rate
Rationale:
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.
Which is a proper nursing action for a patient in acute respiratory failure?
A. Administer 100% oxygen to an intubated patient until the pathology has resolved.
B. Provide chest physical therapy for patients who produce more than 30 mL of sputum per day.
C. Use continuous positive airway pressure (CPAP) if the patient has weak or absent respirations.
D. Administer packed red blood cells to maintain the hemoglobin level at 7 g/dL or higher.
B. Provide chest physical
therapy for patients who produce more than 30 mL of sputum per day.
Chest physical therapy is indicated for patients who produce more than 30 mL of sputum per day or have evidence of atelectasis or pulmonary infiltrates. The selected oxygen delivery system must also maintain PaO2 equal to or more than 55 to 60 mm HG and SaO2 equal or greater than 90% at the lowest O2 concentration possible. High oxygen concentrations replace the nitrogen gas normally present in the alveoli, causing instability and atelectasis. In intubated patients, exposure to 60% or more oxygen for longer than 48 hours poses a significant risk for oxygen toxicity. Noninvasive positive-pressure ventilation such as CPAP is not appropriate for patients who have weak or no respirations (are not inhaling). The hemoglobin level should be equal to or greater than 9 g/dL to ensure adequate oxygen saturation.
What distinguishes hypercapnic respiratory failure from hypoxemic respiratory failure?
A. Low oxygen saturation despite administration of supplemental oxygen
B. Acidemia for which the body cannot compensate
C. Respiration rate greater than 30 breaths/minute
D. Heart rate increases above 100 beats/minute
B. Acidemia for which the body cannot compensate
Hypercapnic respiratory failure is PaCO2 greater than 48 mm Hg in combination with acidemia. The body cannot compensate for the acidemia. Hypoxemic respiratory failure is a PaO2 less than 60 mm Hg despite receiving an inspired oxygen concentration greater than or equal to 60%. The respiratory rate and heart rate are not part of the definitions of these two conditions.
Which patient is most likely going into respiratory failure?
A. A patient who report that he feels short of breath while eating
B. A patient with the following arterial blood gas values over the past 3 hours: pH 7.50, 7.45, and 7.40
C. A patient with an oxygen saturation value of 93%
D. A patient with chronic obstructive pulmonary disease (COPD) who has distant breath sounds
B. A patient with the following arterial blood gas values over the past 3 hours: pH 7.50, 7.45, and 7.40
Manifestations of respiratory failure are related to the extent of change in PaO2 or PaCO2, the rapidity of change, and ability to compensate. It is important to monitor trends. Shortness of breath is a subjective report, and it can have many causes. A single borderline oxygen saturation reading is not as indicative of failure as a negative trend. Because of air trapping with COPD, the breath sounds are typically distant.
A patient with a severe acute asthma exacerbation presents to the emergency department. Over the next hour, the patient remains in respiratory distress, but the respirations have slowed. What is the best explanation?
A. The patient is developing respiratory muscle fatigue.
B. The respirations are exchanging oxygen and carbon dioxide more efficiently.
C. The patient’s anxiety level is lessening.
D. The body has compensated by retaining sodium bicarbonate.
A. The patient is developing respiratory muscle fatigue.
A rapid respiratory rate requires a substantial amount of work. Change from a rapid rate to a slower rate in a patient in acute respiratory distress suggests extreme progression of respiratory muscle fatigue and increased probability of respiratory arrest. Ventilatory exchange, without other indications of improvement, is decreased. As long as the patient is in distress, there is no evidence that anxiety would lessen, and hypoxia would increase anxiety. Compensation through the renal system takes days.
Which signs and symptoms differentiate hypoxemic respiratory failure from hypercapnic respiratory failure (select all that apply)? A. Cyanosis B. Tachypnea C. Morning headache D. Paradoxic breathing E. Pursed-lip breathing
A. Cyanosis
B. Tachypnea
D. Paradoxic breathing
Clinical manifestations that occur with hypoxemic respiratory failure include cyanosis, tachypnea, and paradoxic chest or abdominal wall movement with the respiratory cycle. Clinical manifestations of hypercapnic respiratory failure include morning headache, pursed-lip breathing, and decreased or increase respiratory rate with shallow breathing.
The oxygen delivery system chosen for the patient in acute respiratory failure should
A. always be a low-flow device, such as a nasal cannula.
B. correct the PaO2 to a normal level as quickly as possible.
C. administer positive-pressure ventilation to prevent CO2 narcosis.
D. maintain the PaO2 at ≥60 mm Hg at the lowest O2 concentration possible.
D. maintain the PaO2 at ≥60 mm Hg at the lowest O2 concentration possible.
The selected oxygen delivery system must maintain PaO2 at 55 to 60 mm Hg and SaO2 at 90% or greater at the lowest oxygen concentration possible.
You are admitting a 45-year-old asthmatic patient in acute respiratory distress. You auscultate the patient’s lungs and notice cessation of inspiratory wheezing. The patient has not yet received any medication. What does this finding suggest?
A. Spontaneous resolution of the acute asthma attack
B. An acute development of bilateral pleural effusions
C. Airway constriction requiring intensive interventions
D. Overworked intercostal muscles resulting in poor air exchange
C. Airway constriction requiring intensive interventions
When the patient in respiratory distress has inspiratory wheezing that ceases, it is an indication of airway obstruction, and it requires emergency action to restore the airway.
You are caring for a patient who is admitted with a barbiturate overdose. The patient is unresponsive, with a blood pressure of 90/60 mm Hg, apical pulse of 110 beats/minute, and respiratory rate of 8 breaths/minute. Based on the initial assessment findings, you recognize 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. Hypercapnic respiratory failure related to alveolar hypoventilation
The patient’s respiratory rate is decreased because of barbiturate overdose, which causes respiratory depression. The patient is at risk for hypercapnic respiratory failure resulting from the decreased respiratory rate and decreased CO2 exchange.
You are providing care for an elderly patient who has a low PaO2 as a result of worsening left-sided pneumonia. Which nursing intervention will help the patient mobilize his secretions?
A. Augmented coughing or huff coughing
B. Positioning the patient to lie on his left side
C. Frequent and aggressive nasopharyngeal suctioning
D. Application of noninvasive positive-pressure ventilation (NIPPV)
A. Augmented coughing or huff coughing
Augmented coughing and huff coughing techniques may aid the patient in the mobilization of secretions. If placed in a side-lying position, the patient should be positioned on his right side (good lung down). Suctioning may be indicated, but it should always be performed cautiously because of the risk of hypoxia. NIPPV is inappropriate in the treatment of patients with excessive secretions.
Which intervention is key to preventing ventilator-associated pneumonia as a complication in a patient with acute respiratory distress syndrome (ARDS)?
A. Scheduled prophylactic nasopharyngeal suctioning
B. Instilling normal saline down the endotracheal tube to loosen secretions
C. Providing frequent mouth care and oral hygiene
D. Using high tidal volumes on the ventilator
C. Providing frequent mouth care and oral hygiene
A frequent complication of ARDS is ventilator-associated pneumonia. Preventative strategies include elevating head-of-bed 30-45 degrees and strict infection control measures such as frequent hand washing, use of in-line suction, and frequent mouth care and oral hygiene. Suctioning is done only as needed to prevent stimulating excess secretions. Instilling normal saline does not loosen secretions and can cause hypoxia. It is not recommended. High tidal volumes can lead to barotrauma.
Which is part of the nursing management for ARDS?
A. Aggressive use of intravenous (IV) fluids
B. Administration of a β-blocker
C. Use of positive end-expiratory pressure (PEEP)
D. Use of the lateral recumbent position
C. Use of positive end-expiratory pressure (PEEP)
In ARDS, higher levels of PEEP may be used. It increases the functional residual capacity (FRC) and opens collapsed alveoli. The issues in ARDS treatment are respiratory related, not fluid deficit. β-Blockers are part of myocardial infarction management, not ARDS. Some ARDS patients do better when placed in a prone position instead of a supine position. In the supine position, the heart places pressure on the pleural cavity. Changing the patient to a prone position allows air-filled, nonatelectatic alveoli in the ventral portion of the lung to become dependent.
What is the classic chest x-ray finding in a patient with late-stage ARDS?
A. Hyperinflation
B. Infiltrates in the bases
C. Deflated lung on one side
D. White lung
D. White lung
The chest x-ray image often shows a white-out effect, sometimes called white lung, because consolidation and infiltrates are widespread throughout the lungs, leaving few recognizable air spaces. Hyperinflation typically is seen in chronic obstructive lung disease. There can be some effusions or infiltrates initially with ARDS, but it is more extensive in the late stages and is not only in the bases. Unilateral lung deflation is pneumothorax.
What are the most common early clinical manifestations of ARDS?
A. Dyspnea and tachypnea
B. Cyanosis and apprehension
C. Hypotension and tachycardia
D. Respiratory distress and frothy sputum
A. Dyspnea and tachypnea
The initial manifestations of ARDS are often subtle. At the time of the initial injury and for several hours up to 2 days afterward, the patient may not experience respiratory symptoms, or the patient may exhibit only dyspnea, tachypnea, cough, and restlessness.
Maintenance of fluid balance in the patient with ARDS involves
A. hydration using colloids.
B. administration of surfactant.
C. mild fluid restriction and diuretics as necessary.
D. keeping the hemoglobin level greater than 12 g/dL (120 g/L).
C. mild fluid restriction and diuretics as necessary.
Fluid balance in the patient with acute respiratory distress syndrome includes maintaining the pulmonary artery wedge pressure as low as possible without impairing cardiac output to limit pulmonary edema. The patient is usually placed on mild fluid restriction, and diuretics are used as necessary.
A patient has ARDS resulting from sepsis. Which measure is most likely to be implemented to maintain cardiac output?
A. Administer crystalloid fluids or colloid solutions.
B. Position the patient in the Trendelenburg position.
C. Perform chest physiotherapy and assist with staged coughing.
D. Place the patient on fluid restriction, and administer diuretics.
A. Administer crystalloid fluids or colloid solutions.
Low cardiac output may necessitate crystalloid fluids or colloid solutions in addition to lowering the PEEP or administering inotropes. The Trendelenburg position (not recommended to treat hypotension) and chest physiotherapy are unlikely to relieve decreased cardiac output, and fluid restriction and diuresis are inappropriate interventions.
To evaluate the effectiveness of prescribed therapies for a patient with ventilatory 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
c. Arterial blood gas (ABG) analysis
ABG analysis is most useful in this setting because ventilatory failure causes problems with CO2 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.
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.
d. initiation of bilevel positive pressure ventilation (BiPAP).
b. endotracheal intubation and positive pressure ventilation.
The patient’s lethargy, low respiratory rate, and SpO2 indicate the need for mechanical ventilation with ventilator-controlled 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
When admitting a patient in possible respiratory failure with a high PaCO2, which assessment information will be of most concern to the nurse?
a. The patient is somnolent.
b. The patient’s SpO2 is 90%.
c. The patient complains of weakness.
d. The patient’s blood pressure is 162/94.
a. The patient is somnolent.
Increasing somnolence will decrease the patient’s respiratory rate and further increase the PaCO2 and respiratory failure. Rapid action is needed to prevent respiratory arrest. An SpO2 of 90%, weakness, and elevated blood pressure all require ongoing monitoring but are not indicators of possible impending respiratory arrest.
A patient with acute respiratory distress syndrome (ARDS) and acute renal failure has the following medications prescribed. Which medication should the nurse discuss with the health care provider before administration?
a. ranitidine (Zantac) 50 mg IV
b. gentamicin (Garamycin) 60 mg IV
c. sucralfate (Carafate) 1 g per nasogastric tube
d. methylprednisolone (Solu-Medrol) 40 mg IV
b. gentamicin (Garamycin) 60 mg IV
Gentamicin, which is one of the aminoglycoside antibiotics, is potentially nephrotoxic, and the nurse should clarify the drug and dosage with the health care provider before administration. The other medications are appropriate for the patient with ARDS.
A patient develops increasing dyspnea and hypoxemia 2 days after having cardiac surgery. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by left ventricular failure, the nurse will anticipate assisting with
a. inserting a pulmonary artery catheter.
b. obtaining a ventilation-perfusion scan.
c. drawing blood for arterial blood gases.
d. positioning the patient for a chest radiograph.
a. inserting a pulmonary artery catheter.
Pulmonary artery wedge pressures are normal in the patient with ARDS because the fluid in the alveoli is caused by increased permeability of the alveolar-capillary membrane rather than by the backup of fluid from the lungs (as occurs in cardiogenic pulmonary edema). The other tests will not help in differentiating 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 decreased?
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.
a. The patient has subcutaneous emphysema.
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.”
d. “PEEP prevents the lung air sacs from collapsing during exhalation.”
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.
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.
c. Obtain oxygen saturation using pulse oximetry.
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.
c. Elevate head of bed to 30 to 45 degrees.
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.
d. Increase oxygen level to keep O2 saturation >95%.
b. Offer the patient fluids at frequent intervals.
Since the reason for the poor airway clearance is the thick secretions, the best action will be to encourage the patient to improve oral fluid intake. The use of the incentive spirometer should be more frequent in order to facilitate the clearance of the secretions. The other actions also may be helpful in improving the patient’s gas exchange, but they do not address the thick secretions that are causing the poor airway clearance.
After receiving change-of-shift report, which patient will the nurse assess first?
a. A patient with cystic fibrosis who has thick, green-colored sputum
b. A patient with pneumonia who has coarse crackles in both lung bases
c. A patient with emphysema who has an oxygen saturation of 91% to 92%
d. A patient with septicemia who has intercostal and suprasternal retractions
d. A patient with septicemia who has intercostal and suprasternal retractions
This patient’s history of septicemia and labored breathing suggest the onset of ARDS, which will require rapid interventions such as administration of oxygen and use of positive pressure ventilation. The other patients also should be assessed as quickly as possible, but their assessment data are typical of their disease processes and do not suggest deterioration in their status.
A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department complaining of shortness of breath and dyspnea. Which assessment finding by the nurse is most 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%.
c. The patient’s respiratory rate has decreased from 30 to 10 breaths/min.
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.
The nurse is caring for a 22-year-old patient who came to the emergency department 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.
c. The patient’s PaO2 is 45 mm Hg.
The PaO2 indicates severe hypoxemia and respiratory failure. Rapid action is needed to prevent further 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.
d. Oxygen saturation (SpO2) has dropped to 90% with administration of 100% O2 by non-rebreather mask.
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.
A male patient is admitted to the health care facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this patient?
A. Activity intolerance related to fatigue
B. Anxiety related to actual threat to health status
C. Risk for infection related to retained secretions
D. Impaired gas exchange related to airflow obstruction
D. Impaired gas exchange related to airflow obstruction
A patient airway and an adequate breathing pattern are the top priority for any patient, making “impaired gas exchange related to airflow obstruction” the most important nursing diagnosis. The other options also may apply to this patient but less important.
For a patient with advanced chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange?
A. Encouraging the patient to drink three glasses of fluid daily
B. Keeping the patient in semi-fowler’s position
C. Using a high-flow venturi mask to deliver oxygen as prescribe
D. Administering a sedative, as prescribe
C. Using a high-flow venturi mask to deliver oxygen as prescribe
The patient with COPD retains carbon dioxide, which inhibits stimulation of breathing by the medullary center in the brain. As a result, low oxygen levels in the blood stimulate respiration, and administering unspecified, unmonitored amounts of oxygen may depress ventilation. To promote adequate gas exchange, the nurse should use a Venturi mask to deliver a specified, controlled amount of oxygen consistently and accurately. Drinking three glasses of fluid daily would not affect gas exchange or be sufficient to liquefy secretions, which are common in COPD. Patients with COPD and respiratory distress should be places in high-Fowler’s position and should not receive sedatives or other drugs that may further depress the respiratory center.
The low tidal volume alarm on a client’s ventilator keeps sounding. What is the nurse’s first action?
A) Manually ventilate the client.
B) Put air into the endotracheal tube cuff.
C) Check ventilator connections.
D) Call the physician.
C) Check ventilator connections.
Rationale: Ventilator connections should be check initially and loose connections or disconnections should be fixed. If there is no immediate problem found, the client should be manually ventilated and another person should check the ventilator connections. Test Plan: Management of care
A client has just been intubated for placement on a mechanical ventilator. What is the first assessment of the tube placement?
A) Chest X-Ray
B) Auscultation of breath sounds
C) Pulse oximetry reading of 95%
D) End tidal CO2 monitoring
D) End tidal CO2 monitoring
Rationale: End tidal CO2 monitoring is the first intervention to determine if the endotracheal tube is in place, but a chest x-ray is still needed to confirm proper placement.
What are strategies to prevent Ventilator-associated Pneumonia? select all that apply
A. Oral care every 4 hours,
B. HOB elevated 30-45 degrees unless contraindicated by the patient’s condition
C. HOB elevated 10-15 degrees, unless contraindicated by the patient’s condition
D. Allow family to suction patient as needed to remove secretions
A. Oral care Q4h
B. HOB elevated 30-45 degrees unless contraindicated by patients condition.
A Client has been intubated and placed on a volume-cycled mechanical ventilator. The nurse carefully assess the client for findings associated with a risk associated with this type of ventilator. What is the risk?
A. Hypoventilation
B. Hypercapnia
C. Respiratory acidosis
D. Barotrauma
D. Barotrauma
rationale: the volume-cycled ventilator has the potential to increase pressure in order to deliver the set volume. barotrauma is a risk associated with this form of mechanical ventilation.
A patient is placed on volume-cycled ventilation. The nurse plans care for this client based on which characteristic of this method of ventilation?
A. Delivers a set volume, which will help overcome the client’s airway resistance changes.
B. The mechanism by which the phase of the breath switches from inspiration to expiration.
C. Provides a consistent tidal volume.
D. Delivers a preset volume of gas to the lungs to generate high pressures.
A. Delivers a set volume, which will help overcome the client’s airway resistance changes.
Rationale: Volume- cycled ventilation delivers a preset volume of gas to the lungs, making volume constant therefore, overcoming the changes in lung compliance and airway resistance.
The client is on CPAP for weaning from a mechanical ventilator. Assessment reveals a respiratory rate of 32/min, oxygen saturation of 88 percent, and use of accessory muscles. What should the nurse anticipate will occur?
A. The FiO2 will be increased.
B. Weaning will continue.
C. The client will be placed back on full ventilatory support.
D. The client will be extubated.
C. The client will be placed back on full ventilatory support.
Rationale: Weaning should be discontinued, as the client is showing signs of intolerance.
The nurse administers amiodarone (Cordarone) to a client with ventricular tachycardia. Which monitoring by the nurse is necessary with this drug? Select all that apply.
a. Respiratory rate
b. QT interval
c. Heart rate and rhythm
d. Magnesium level
e. Urine output
b. QT interval
c. Heart rate and rhythm
d. Magnesium level
B. Amiodarone causes prolongation of the QT interval, which can precipitate dysrhythmia.
C. Antidysrhythmic medications cause changes in cardiac rhythm and rate; therefore monitoring of heart rate and rhythm is needed.
D. Electrolyte depletion, specifically potassium and magnesium, may predispose to further dysrhythmia.)
The nurse is caring for a client with acute coronary syndrome (ACS) and atrial fibrillation who has a new prescription for metoprolol (Toprol). Which monitoring is essential when administering the medication?
a. ST segment
b. Heart rate
c. Troponin
d. Myoglobin
b. Heart rate
The effect of metoprolol are to decrease heart rate, blood pressure, and myocardial oxygen demand.
The nurse is caring for a client with atrial fibrillation. In addition to an antidysrhythmic, what medication does the nurse plan to administer?
a. Heparin
b. Atropine
c. Dobutamine
d. Magnesium sulfate
a. Heparin
(Clients with atrial fibrillation are prone to blood pooling in the atrium, clotting, then embolizing. Heparin is used to prevent thrombus development in the atrium and the consequences of embolization (i.e., stroke).)
The nurse is caring for a client on a telemetry unit with a regular heart rhythm and rate of 60; a P wave precedes each QRS complex, and the PR interval is 0.24 second. Additional vital signs are as follows: blood pressure 118/68, respiratory rate 16, and temperature 98.8° F. The following medications are available on the medication record. What action should the nurse take?
a. Administer atropine
b. Administer digoxin
c. Administer clonidine
d. Continue to monitor
d. Continue to monitor
(The client is displaying sinus rhythm with first-degree atrioventricular heart block; this is usually asymptomatic and does not require treatment.)
You are the charge nurse on the telemetry unit and are responsible for making client assignments. Which client would be appropriate to assign to the float RN from the medical-surgical unit?
a. The 64-year-old admitted for weakness who has a first-degree heart block with a heart rate of 58 beats/min
b. The 71-year-old admitted for heart failure who is short of breath and has a heart rate of 120 to 130 beats/min
c. The 88-year-old admitted with an elevated troponin level who is hypotensive with a heart rate of 96 beats/min
d. The 92-year-old admitted with chest pain who has premature ventricular complexes and a heart rate of 102 beats/min
a. The 64-year-old admitted for weakness who has a first-degree heart block with a heart rate of 58 beats/min
(The client has a stable, asymptomatic dysrhythmia, which usually requires no treatment; this client can be managed by a nurse with less cardiac dysrhythmia training.)
A client with atrial fibrillation with rapid ventricular response has received medication to slow the ventricular rate. The pulse is now 88. For which additional therapy does the nurse plan?
a. Synchronized cardioversion
b. Electrophysiology studies (EPS)
c. Anticoagulation
d. Radiofrequency ablation therapy
c. Anticoagulation
Because of the risk for thromboembolism, anticoagulation is necessary.
The nurse is caring for a client with unstable angina whose cardiac monitor shows ventricular tachycardia. Which action is appropriate to implement first?
a. Defibrillate the client at 200 J.
b. Check the client for a pulse.
c. Cardiovert the client at 50 J.
d. Give the client IV lidocaine.
b. Check the client for a pulse.
(The nurse needs to assess the client to determine stability before proceeding with further interventions. If the client has a pulse and is relatively stable, elective cardioversion or antidysrhythmic medications may be prescribed.)
A client admitted after using crack cocaine develops ventricular fibrillation. After determining unresponsiveness, which action should the nurse take next?
a. Defibrillate at 200 J.
b. Establish IV access.
c. Place an oral airway and ventilate.
d. Start cardiopulmonary resuscitation (CPR).
a. Defibrillate at 200 J.
(Defibrillating is of priority before any other resuscitative measures according to Advanced Cardiac Life Support protocols.)
Which information would cause the nurse to withhold digoxin in the client with atrial fibrillation and heart failure?
a. The client has sinus tachycardia with a rate of 102.
b. The cardiac monitor shows atrial fibrillation with a heart rate of 98.
c. The client has a creatinine level of 1.0 mg/dL.
d. The digoxin level is 2.8 mg/dL.
d. The digoxin level is 2.8 mg/dL.
The therapeutic range for digoxin is 0.8 to 2.0 ng/mL; hold the medication because this client has digoxin toxicity.
In teaching clients at risk for bradydysrhythmias, what information does the nurse include?
a. “Avoid potassium-containing foods.”
b. “Stop smoking and avoid caffeine.”
c. “Take nitroglycerin for a slow heartbeat.”
d. “Use a stool softener.”
d. “Use a stool softener.”
(Clients at risk for bradydysrhythmias should avoid bearing down or straining during a bowel movement; the Valsalva maneuver can cause bradycardia. Taking a stool softener helps to prevent this.)
The nurse is determining whether the client’s rhythm strip demonstrates proper firing of the sinoatrial (SA) node. Which waveform indicates proper function of the SA node?
a. The QRS complex is present.
b. The PR interval is 0.24 second.
c. A P wave precedes every QRS complex.
d. The ST segment is elevated.
c. A P wave precedes every QRS complex.
A P wave is generated by the SA node and represents atrial depolarization.
The professional nurse is supervising a nursing student performing a 12-lead electrocardiogram (ECG). Under which circumstance does the nurse correct the student?
a. The client is semirecumbent in bed.
b. Chest leads are placed as for the previous ECG.
c. The client is instructed to breath deeply through the mouth.
d. The client is instructed to lie still.
c. The client is instructed to breath deeply through the mouth.
(Normal breathing is required or artifact will be observed, perhaps leading to inaccurate interpretation of the ECG.)
Which teaching is essential for a client who has a permanent pacemaker inserted?
a. Avoid talking on a cell phone
b. Avoid contact sports and blows to the chest
c. Avoid sexual activity
d. Do not take tub baths
b. Avoid contact sports and blows to the chest
No pressure should be applied over generator.
The nurse is caring for a client with heart rate of 143 beats/min. For which manifestation should the nurse observe? Select all that apply.
a. Palpitations
b. Increased energy
c. Chest discomfort
d. Flushing of the skin
e. Hypotension
a. Palpitations
c. Chest discomfort
e. Hypotension
(A. Tachycardia, heart rate greater than 100 beats/min, produces palpitations, that is, the ability to feel the heart beating in the chest.
C. Chest discomfort may occur because decreased time for diastole results in lower perfusion through the coronary arteries to the myocardium.
E. Hypotension results from decreased time for ventricular filling, secondary to shortened diastole and therefore reduced cardiac output and blood pressure.)
The nurse is caring for a client who has developed a bradycardia. Which possible causes should the nurse investigate? Select all that apply.
a. Bearing down for a bowel movement
b. Possible inferior wall myocardial infarction (MI)
c. Client stating that he just had a cup of coffee
d. Client becoming emotional when visitors arrived
e. Diltiazem (Cardizem) administered an hour ago
a. Bearing down for a bowel movement
b. Possible inferior wall myocardial infarction (MI)
e. Diltiazem (Cardizem) administered an hour ago
(A. The Valsalva maneuver stimulates the vagus nerve, causing bradycardia.
B. Inferior wall MI is a cause of bradycardia and heart blocks.
E. Calcium channel blockers such as diltiazem may cause bradycardia.)
How does the nurse recognize that atropine has produced a positive outcome for the client with bradycardia?
a. Client states he is dizzy and weak.
b. The nurse notes dyspnea.
c. The client has a heart rate of 42.
d. The monitor shows sinus rhythm.
d. The monitor shows sinus rhythm.
Sinus rhythm presents with heart rates from 60 to 100 beats/min; by definition, the bradydysrhythmia has resolved.
While shopping at the local mall, a bystander witnesses a shopper grab his chest and fall to the floor. The bystander opens the victim’s airway and begins CPR. The security guard arrives with the AED. What is the correct sequence of steps for using the AED? Select in priority order.
A. Place AED pads on victim’s chest.
B. Press the button to analyze the rhythm.
C. Turn on the AED.
D. Connect pads to the AED.
E. Press the button to shock if indicated.
A. Place AED pads on victim’s chest.
D. Connect pads to the AED.
C. Turn on the AED.
B. Press the button to analyze the rhythm.
E. Press the button to shock if indicated.
(Shocks are recommended for VF or pulseless VT only.)
Which teaching is essential for a client who has had a permanent pacemaker inserted?
a. Avoid talking on a cell phone
b. Avoid operating electrical appliances over the pacemaker
c. Avoid sexual activity
d. Do not take tub baths
b. Avoid operating electrical appliances over the pacemaker
(The client should avoid operating electrical appliances directly over the pacemaker site because this may cause the pacemaker to malfunction.)
The nurse teaches a client with new-onset atrial fibrillation that risk factors for this dysrhythmia may include which? Select all that apply.
a. Use of beta-adrenergic blockers
b. Excessive alcohol use
c. Advancing age
d. High blood pressure
e. Palpitations
b. Excessive alcohol use
c. Advancing age
d. High blood pressure
(B. Excessive alcohol use may cause atrial fibrillation.
C. Atrial fibrillation occurs more frequently in older people.
D. Hypertension is a risk factor in the development of atrial fibrillation.)
What teaching does the nurse include for a client with atrial fibrillation who has a new prescription for warfarin?
a. It is important to consume a diet high in green leafy vegetables.
b. You should take aspirin or ibuprofen for headache.
c. Report nosebleeds to your provider immediately.
d. Avoid caffeinated beverages.
c. Report nosebleeds to your provider immediately.
Warfarin causes decreased ability to clot; a nosebleed could be indicative of excessive dosing.
The nurse is caring for a client with advanced heart failure who develops asystole. The nurse corrects the new graduate when the graduate offers to perform which intervention?
a. Defibrillation
b. Cardiopulmonary resuscitation (CPR)
c. Administration of atropine
d. Administration of oxygen
a. Defibrillation
(Defibrillation interrupts the heart rhythm and allows normal pacemaker cells to take over; in asystole, there is no rhythm to interrupt; therefore this intervention is not used.)
The nurse receives in report that the client with a pacemaker has experienced loss of capture. Which situation is consistent with this?
a. The pacemaker spike falls on the T wave.
b. Pacemaker spikes are noted, but no P wave or QRS complex follows.
c. The heart rate is 42, and no pacemaker spikes are seen on the rhythm strip.
d. The client demonstrates hiccups.
b. Pacemaker spikes are noted, but no P wave or QRS complex follows.
(Loss of capture occurs when the pacing stimulus (spike) is not followed by the appropriate response, either P wave or QRS complex, depending on placement of the pacing electrode.)
The nurse recognizes that which intervention provides safety during cardioversion?
a. Using the defibrillator at 200 joules
b. Obtaining informed consent
c. Setting defibrillator to synchronized mode
d. Removing oxygen
c. Setting defibrillator to synchronized mode
(Setting the defibrillator to the synchronized mode ensures discharging the shock during the vulnerable period on the T wave, which may cause ventricular fibrillation.)
The client’s rhythm strip shows a heart rate of 76 beats/min, one P wave occurring before each QRS complex, a PR interval measuring 0.24 second, and a QRS complex measuring 0.08 second. How does the nurse interpret this rhythm strip?
a. Normal sinus rhythm
b. Sinus bradycardia
c. Sinus rhythm with first-degree atrioventricular (AV) block
d. Sinus rhythm with premature ventricular contractions
c. Sinus rhythm with first-degree atrioventricular (AV) block
(These are the characteristics of sinus rhythm with first-degree AV block.)
The nurse is teaching the client with a new permanent pacemaker. Which statement by the client indicates the need for further discharge education?
a. “I will be able to shower again soon.”
b. “I need to take my pulse every day.”
c. “I might trigger airport security metal detectors.”
d. “I no longer need my heart pills.”
d. “I no longer need my heart pills.”
All discharge medications are still needed after the pacemaker is implanted.
Which client is appropriate for the cardiac care unit charge nurse to assign to the float RN from the medical-surgical unit?
a. The 64-year-old client admitted for weakness who has a sinus bradycardia with a heart rate of 58 beats/min
b. The 71-year-old client admitted for heart failure who is short of breath and has a heart rate of 120 to 130 beats/min
c. The 88-year-old client admitted with an elevated troponin level who is hypotensive with a heart rate of 96 beats/min
d. The 92-year-old client admitted with chest pain who has premature ventricular complexes and a heart rate of 102 beats/min
a. The 64-year-old client admitted for weakness who has a sinus bradycardia with a heart rate of 58 beats/min
(The 64-year-old has a stable, asymptomatic bradycardia, which usually requires monitoring but no treatment unless the client develops symptoms and/or the slow heart rate causes a decrease in cardiac output.)
The nurse is caring for a client with unstable angina whose cardiac monitor shows ventricular tachycardia. Which action is appropriate to implement first?
a. Defibrillate using 200 J.
b. Check the client for a pulse.
c. Cardiovert the client at 50 J.
d. Administer IV ibutilide (Corvert).
b. Check the client for a pulse.
(The nurse needs to assess the pulse and client stability before proceeding with further interventions; pulseless ventricular tachycardia is treated with defibrillation.)
A client’s rhythm strip shows a heart rate of 116 beats/min, one P wave occurring before each QRS complex, a PR interval measuring 0.16 second, and a QRS complex measuring 0.08 second. How does the nurse interpret this rhythm strip?
a. Normal sinus rhythm
b. Sinus bradycardia
c. Sinus tachycardia
d. Sinus rhythm with premature ventricular contractions
c. Sinus tachycardia
An older client has been taking metoprolol (Toprol) for hypertension for the past 3 days. Her daughter states that she has become confused, dizzy, and weak since starting the drug. How with the telephone triage nurse response to the daughter’s concerns?
a. “She’s getting older, so confusion is common from aging.”
b. “Did your mother pass out at any time in the past few days?”
c. “Tell your mother to stop taking the metoprolol for a week.”
d. “Tell your mother to only take half of the drug today.”
b. “Did your mother pass out at any time in the past few days?”
(The nurse should assess for syncopal episodes related to bradycardia. Metoprolol (Toprol) is a beta-blocker and can lead to a decreased heart rate. Symptoms related to bradycardia may also include dizziness and weakness, confusion, hypotension, diaphoresis, shortness of breath, and chest pain.)
What is the most appropriate assessment for the nurse to evaluate whether a client has adequate cardiac output and tissue perfusion?
a. Assess for cyanosis of the hands and feet.
b. Assess for pulmonary edema.
c. Monitor respiratory status for shortness of breath.
d. Monitor blood pressure and urine output.
c. Monitor respiratory status for shortness of breath.
(Clients experiencing decreased cardiac output will have impaired oxygenation and thus decreased tissue perfusion. Shortness of breath may be a manifestation of decreased cardiac output.)
A client is on a cardiac monitor. The nurse suddenly notices there are no ECG complexes and the alarm sounds. What is the priority action of the nurse?
a. Begin chest compressions and ventilations.
b. Assess the client and check lead placement.
c. Call a code blue and shout for help.
d. Press the record button to get an ECG strip.
b. Assess the client and check lead placement.
(The first action to take when the monitor does not display a complex and the alarm sounds is check for the placement of leads. A lead that has come off the client’s chest wall will cause the monitor to alarm. It is not unusual for a lead to be displaced due to diaphoresis, movement, or poor attachment. Checking the placement of leads should be done before beginning CPR, calling for help, instituting a code blue, or using the ECG machine for assessment.)
A client reports “not feeling well for the past week” after taking digoxin (Lanoxin), which was prescribed a month ago. Which statement by the client indicates possible digoxin toxicity?
a. “I am short of breath and my hands are swollen.”
b. “I have chest pain and tingling in my fingers.”
c. “I have double vision and feel sick to my stomach.”
d. “I am constipated and have trouble sleeping.”
c. “I have double vision and feel sick to my stomach.”
(Side effects from digoxin include rash; hives; itching; difficulty breathing; tightness in the chest; swelling of the mouth, face, lips, or tongue; blurred or double vision and yellow vision; confusion; fast, slow, or irregular heartbeat; hallucinations; mood or mental changes; severe or persistent nausea, vomiting, or stomach pain; unusual bruising or bleeding; and unusual tiredness or weakness. Clients experiencing an adverse reaction to digoxin may feel fatigued or have diarrhea. )
The nurse teaches a 28-year-old man newly diagnosed with hypertension about lifestyle modifications to reduce his blood pressure. Which statement by the patient requires an intervention by the nurse?
A “I will avoid adding salt to my food during or after cooking.”
B “If I lose weight, I might not need to continue taking medications.”
C “I can lower my blood pressure by switching to smokeless tobacco.”
D “Diet changes can be as effective as taking blood pressure medications.”
C “I can lower my blood pressure by switching to smokeless tobacco.”
Nicotine contained in tobacco products (smoking and chew) cause vasoconstriction and increase blood pressure. Persons with hypertension should restrict sodium to 1500 mg/day by avoiding foods high in sodium and not adding salt in preparation of food or at meals. Weight loss can decrease blood pressure between 5 to 20 mm Hg. Following dietary recommendations (such as the DASH diet) lowers blood pressure, and these decreases compare with those achieved with blood pressure-lowering medication.
The nurse supervises an unlicensed assistant personnel (UAP) who is taking the blood pressure of 58-year-old female patient admitted with heart failure. The patient is obese. The nurse should intervene if what is observed?
A. The UAP waits 2 minutes after position changes to take orthostatic pressures.
B. The UAP deflates the blood pressure cuff at a rate of 8 to 10 mm Hg per second.
C. The UAP takes the blood pressure with the patient’s arm at the level of the heart.
D. The UAP takes a forearm blood pressure because the largest cuff will not fit the patient’s upper arm.
B. The UAP deflates the blood pressure cuff at a rate of 8 to 10 mm Hg per second.
The UAP deflates the blood pressure cuff at a rate of 8 to 10 mm Hg per second.
The cuff should be deflated at a rate of 2 to 3 mm Hg per second. The arm should be supported at the level of the heart for accurate blood pressure measurements. If the maximum size blood pressure cuff does not fit the upper arm, the forearm may be used. Orthostatic blood pressures should be taken within 1 to 2 minutes of repositioning the patient.
A 44-year-old man is diagnosed with hypertension and receives a prescription for benazepril (Lotensin). After the nurse teaches him about the medication, which statement by the patient indicates his correct understanding?
A. “If I take this medication, I will not need to follow a special diet.”
B. “It is normal to have some swelling in my face while taking this medication.”
C. “I will need to eat foods such as bananas and potatoes that are high in potassium.”
D. “If I develop a dry cough while taking this medication, I should notify my doctor.”
D. “If I develop a dry cough while taking this medication, I should notify my doctor.”
Benazepril is an angiotensin-converting enzyme inhibitor. The medication inhibits breakdown of bradykinin, which may cause a dry, hacking cough. Other adverse effects include hyperkalemia. Swelling in the face could indicate angioedema and should be reported immediately to the prescriber. Patients taking drug therapy for hypertension should also attempt lifestyle modifications to lower blood pressure such as a reduced-sodium diet.
A 67-year-old woman with a history of coronary artery disease and prior myocardial infarction is admitted to the emergency department with a blood pressure of 234/148 mm Hg and started on IV nitroprusside (Nitropress). What should the nurse determine as an appropriate goal for the first hour of treatment?
A. Mean arterial pressure lower than 70 mm Hg
B. Mean arterial pressure no more than 120 mm Hg
C. Mean arterial pressure no lower than 133 mm Hg
D. Mean arterial pressure between 70 and 110 mm Hg
C. Mean arterial pressure no lower than 133 mm Hg
The initial treatment goal is to decrease mean arterial pressure by no more than 25% within minutes to 1 hour. If the patient is stable, the goal for BP is 160/100 to 110 mm Hg over the next 2 to 6 hours. Lowering the blood pressure too much may decrease cerebral, coronary, or renal perfusion and could precipitate a stroke, myocardial infarction, or renal failure. Additional gradual reductions toward a normal blood pressure should be implemented over the next 24 to 48 hours if the patient is clinically stable.
The nurse admits a 73-year-old male patient with dementia for treatment of uncontrolled hypertension. The nurse will closely monitor for hypokalemia if the patient receives which medication?
A. Clonidine (Catapres)
B. Bumetanide (Bumex)
C. Amiloride (Midamor)
D. Spironolactone (Aldactone)
B. Bumetanide (Bumex)
Bumetanide is a loop diuretic. Hypokalemia is a common adverse effect of this medication. Amiloride is a potassium-sparing diuretic. Spironolactone is an aldosterone-receptor blocker. Hyperkalemia is an adverse effect of both amiloride and spironolactone. Clonidine is a central-acting α-adrenergic antagonist and does not cause electrolyte abnormalities.
The nurse teaches a patient with hypertension that uncontrolled hypertension may damage organs in the body primarily by which mechanism?
A. Hypertension promotes atherosclerosis and damage to the walls of the arteries.
B. Hypertension causes direct pressure on organs, resulting in necrosis and replacement of cells with scar tissue.
C. Hypertension causes thickening of the capillary membranes, leading to hypoxia of organ systems.
D. Hypertension increases blood viscosity, which contributes to intravascular coagulation and tissue necrosis distal to occlusions.
A. Hypertension promotes atherosclerosis and damage to the walls of the arteries.
Hypertension promotes atherosclerosis and damage to the walls of the arteries.
Hypertension is a major risk factor for the development of atherosclerosis by mechanisms not yet fully known. However, once atherosclerosis develops, it damages the walls of arteries and reduces circulation to target organs and tissues.
When teaching a patient about dietary management of stage 1 hypertension, which instruction is most appropriate?
A. Restrict all caffeine.
B. Restrict sodium intake.
C. Increase protein intake.
D. Use calcium supplements.
B. Restrict sodium intake.
The patient should decrease intake of sodium. This will help to control hypertension, which can be aggravated by excessive salt intake, which in turn leads to fluid retention. Caffeine and protein intake do not affect hypertension. Calcium supplements are not recommended to lower BP.
In caring for a patient admitted with poorly controlled hypertension, which laboratory test result should the nurse understand as indicating the presence of target organ damage?
A. BUN of 15 mg/dL
B. Serum uric acid of 3.8 mg/dL
C. Serum creatinine of 2.6 mg/dL
D. Serum potassium of 3.5 mEq/L
C. Serum creatinine of 2.6 mg/dL
The normal serum creatinine level is 0.6-1.3 mg/dL. This elevated level indicates target organ damage to the kidneys. The other lab results are within normal limits.
When providing dietary instruction to a patient with hypertension, the nurse would advise the patient to restrict intake of which meat?
A. Broiled fish
B. Roasted duck
C. Roasted turkey
D. Baked chicken breast
B. Roasted duck
Roasted duck is high in fat, which should be avoided by the patient with hypertension. Weight loss may slow the progress of atherosclerosis and overall CVD risk. The other meats are lower in fat and are therefore acceptable in the diet.
The nurse is caring for a patient admitted with a history of hypertension. The patient’s medication history includes hydrochlorothiazide (Hydrodiuril) daily for the past 10 years. Which parameter would indicate the optimal intended effect of this drug therapy?
A. Weight loss of 2 lb
B. Blood pressure 128/86
C. Absence of ankle edema
D. Output of 600 mL per 8 hours
B. Blood pressure 128/86
Hydrochlorothiazide may be used alone as monotherapy to manage hypertension or in combination with other medications if not effective alone. After the first few weeks of therapy, the diuretic effect diminishes, but the antihypertensive effect remains. Since the patient has been taking this medication for 10 years, the most direct measurement of its intended effect would be the blood pressure.
In reviewing medication instructions with a patient being discharged on antihypertensive medications, which statement would be most appropriate for the nurse to make when discussing guanethidine (Ismelin)?
A. “A fast heart rate is a side effect to watch for while taking guanethidine.”
B. “Stop the drug and notify your doctor if you experience any nausea or vomiting.”
C. “Because this drug may affect the lungs in large doses, it may also help your breathing.”
D. “Make position changes slowly, especially when rising from lying down to a standing position.”
D. “Make position changes slowly, especially when rising from lying down to a standing position.”
Guanethidine is a peripheral-acting α-adrenergic antagonist and can cause marked orthostatic hypotension. For this reason, the patient should be instructed to rise slowly, especially when moving from a recumbent to a standing position. Support stockings may also be helpful. Tachycardia or lung effects are not evident with guanethidine.
The nurse is caring for a patient admitted with chronic obstructive pulmonary disease (COPD), angina, and hypertension. Before administering the prescribed daily dose of atenolol 100 mg PO, the nurse assesses the patient carefully. Which adverse effect is this patient at risk for, given the patient’s health history?
A. Hypocapnia
B. Tachycardia
C. Bronchospasm
D. Nausea and vomiting
C. Bronchospasm
Atenolol is a cardioselective β1-adrenergic blocker that reduces blood pressure and could affect the β2-receptors in the lungs with larger doses or with drug accumulation. Although the risk of bronchospasm is less with cardioselective β-blockers than nonselective β-blockers, atenolol should be used cautiously in patients with COPD.
The nurse is caring for a patient with hypertension who is scheduled to receive a dose of esmolol (Brevibloc). The nurse should withhold the dose and consult the prescribing physician for which vital sign taken just before administration?
A. Pulse 48
B. Respirations 24
C. Blood pressure 118/74
D. Oxygen saturation 93%
A. Pulse 48
Because esmolol is a β1-adrenergic blocking agent, it can cause hypotension and bradycardia as adverse effects. The nurse should withhold the dose and consult with the health care provider for parameters regarding pulse rate limits.
When teaching how lisinopril (Zestril) will help lower the patient’s blood pressure, which mechanism of action should the nurse use to explain it?
A. Blocks β-adrenergic effects.
B. Relaxes arterial and venous smooth muscle.
C. Inhibits conversion of angiotensin I to angiotensin II.
D. Reduces sympathetic outflow from central nervous system.
C. Inhibits conversion of angiotensin I to angiotensin II.
Lisinopril is an angiotensin-converting enzyme (ACE) inhibitor that inhibits the conversion of angiotensin I to angiotensin II, which reduces angiotensin II-mediated vasoconstriction and sodium and water retention. Beta blockers result in vasodilation and decreased heart rate. Direct vasodilators relax arterial and venous smooth muscle. Central acting α-adrenergic antagonists reduce sympathetic outflow from the CNS to produce vasodilation and decreased SVR and BP.
Despite a high dosage, a male patient who is taking nifedipine (Procardia XL) for antihypertensive therapy continues to have blood pressures over 140/90 mmHg. What should the nurse do next?
A. Assess his adherence to therapy.
B. Ask him to make an exercise plan.
C. Instruct him to use the DASH diet.
D. Request a prescription for a thiazide diuretic.
A. Assess his adherence to therapy.
A long-acting calcium-channel blocker such as nifedipine causes vascular smooth muscle relaxation resulting in decreased SVR and arterial BP and related side effects. The patient data the nurse has about this patient is very limited, so the nurse needs to assess his adherence to therapy.
The nurse is teaching a women’s group about prevention of hypertension. What information should be included in the teaching for all the women (select all that apply)?
A. Lose weight. B. Limit nuts and seeds. C. Limit sodium and fat intake. D. Increase fruits and vegetables. E. Exercise 30 minutes most days.
C Limit sodium and fat intake.
D Increase fruits and vegetables.
E Exercise 30 minutes most days.
Primary prevention of hypertension is to make lifestyle modifications that prevent or delay the increase in BP. Along with exercise for 30 minutes on most days, the DASH eating plan is a healthy way to lower BP by limiting sodium and fat intake, increasing fruits and vegetables, and increasing nutrients that are associated with lowering BP. Nuts and seeds and dried beans are used for protein intake. Weight loss may or may not be necessary for the individual.
When assessing the patient for orthostatic hypotension, after taking the blood pressure (BP) and pulse (P) in the supine position, what should the nurse do next?
A. Repeat BP and P in this position.
B. Take BP and P with patient sitting.
C. Record the BP and P measurements.
D. Take BP and P with patient standing.
B. Take BP and P with patient sitting.
When assessing for orthostatic changes in BP after measuring BP in the supine position, the patient is placed in a sitting position and BP is measured within 1 to 2 minutes and then repositioned to the standing position with BP measured again, within 1 to 2 minutes. The results are then recorded with a decrease of 20 mm Hg or more in SBP, a decrease of 10 mm Hg or more in DBP, and/or an increase in pulse of greater than or equal to 20 beats/minute from supine to standing indicating orthostatic hypotension.
The patient has chronic hypertension. Today she has gone to the ED, and her blood pressure has risen to 200/140. What is the priority assessment for the nurse to make?
A. Is the patient pregnant?
B. Does the patient need to urinate?
C. Does the patient have a headache or confusion?
D. Is the patient taking antiseizure medications as prescribed?
C. Does the patient have a headache or confusion?
The nurse’s priority assessments include neurologic deficits, retinal damage, heart failure, pulmonary edema, and renal failure. The headache or confusion could be seen with hypertensive encephalopathy from increased cerebral capillary permeability leading to cerebral edema. Pregnancy can lead to secondary hypertension. Needing to urinate and taking antiseizure medication do not support a hypertensive emergency.
Which is a proper nursing action for a patient in acute respiratory failure?
A. Administer 100% oxygen to an intubated patient until the pathology has resolved.
B. Provide chest physical therapy for patients who produce more than 30 mL of sputum per day.
C. Use continuous positive airway pressure (CPAP) if the patient has weak or absent respirations.
D. Administer packed red blood cells to maintain the hemoglobin level at 7 g/dL or higher.
B. Provide chest physical therapy for patients who produce more than 30 mL of sputum per day.
Chest physical therapy is indicated for patients who produce more than 30 mL of sputum per day or have evidence of atelectasis or pulmonary infiltrates. The selected oxygen delivery system must also maintain PaO2 equal to or more than 55 to 60 mm HG and SaO2 equal or greater than 90% at the lowest O2 concentration possible. High oxygen concentrations replace the nitrogen gas normally present in the alveoli, causing instability and atelectasis. In intubated patients, exposure to 60% or more oxygen for longer than 48 hours poses a significant risk for oxygen toxicity. Noninvasive positive-pressure ventilation such as CPAP is not appropriate for patients who have weak or no respirations (are not inhaling). The hemoglobin level should be equal to or greater than 9 g/dL to ensure adequate oxygen saturation.
What distinguishes hypercapnic respiratory failure from hypoxemic respiratory failure?
A. Low oxygen saturation despite administration of supplemental oxygen
B. Acidemia for which the body cannot compensate
C. Respiration rate greater than 30 breaths/minute
D. Heart rate increases above 100 beats/minute
B. Acidemia for which the body cannot compensate
Hypercapnic respiratory failure is PaCO2 greater than 48 mm Hg in combination with acidemia.
The body cannot compensate for the acidemia. Hypoxemic respiratory failure is a PaO2 less than 60 mm Hg despite receiving an inspired oxygen concentration greater than or equal to 60%. The respiratory rate and heart rate are not part of the definitions of these two conditions.
A patient with a severe acute asthma exacerbation presents to the emergency department. Over the next hour, the patient remains in respiratory distress, but the respirations have slowed.
What is the best explanation?
A. The patient is developing respiratory muscle fatigue.
B. The respirations are exchanging oxygen and carbon dioxide more efficiently.
C. The patient’s anxiety level is lessening.
D. The body has compensated by retaining sodium bicarbonate.
A. The patient is developing respiratory muscle fatigue.
A rapid respiratory rate requires a substantial amount of work. Change from a rapid rate to a slower rate in a patient in acute respiratory distress suggests extreme progression of respiratory muscle fatigue and increased probability of respiratory arrest. Ventilatory exchange, without other indications of improvement, is decreased. As long as the patient is in distress, there is no evidence that anxiety would lessen, and hypoxia would increase anxiety. Compensation through the renal system takes days.
Which patient is having the most difficulty breathing?
A. The patient who reports one-pillow orthopnea
B. The patient with an inspiratory to expiratory ratio of 1:2
C. The patient who speaks a sentence before breathing
D. The patient with paradoxic breathing
D. The patient with paradoxic breathing
Paradoxic breathing indicates severe distress. The thorax and abdomen normally move outward on inspiration and inward on exhalation. During paradoxic breathing, the abdomen and chest move in the opposite manner, and the pattern results from maximal use of the accessory muscles of respiration. Orthopnea, measured by the number of pillows needed to breathe comfortably, is associated with the use of one to four pillows. One pillow indicates a minor condition. Normal inspiratory to expiratory ratio is 1:2. Speaking in sentences before having to take a breath indicates mild or no distress.
Which signs and symptoms differentiate hypoxemic respiratory failure from hypercapnic respiratory failure (select all that apply)?
A. Cyanosis B. Tachypnea C. Morning headache D. Paradoxic breathing E. Pursed-lip breathing
A. Cyanosis
B. Tachypnea
D. Paradoxic breathing
Clinical manifestations that occur with hypoxemic respiratory failure include cyanosis, tachypnea, and paradoxic chest or abdominal wall movement with the respiratory cycle. Clinical manifestations of hypercapnic respiratory failure include morning headache, pursed-lip breathing, and decreased or increase respiratory rate with shallow breathing.
The oxygen delivery system chosen for the patient in acute respiratory failure should
A. always be a low-flow device, such as a nasal cannula.
B. correct the PaO2 to a normal level as quickly as possible.
C. administer positive-pressure ventilation to prevent CO2 narcosis.
D. maintain the PaO2 at ≥60 mm Hg at the lowest O2 concentration possible.
D. maintain the PaO2 at ≥60 mm Hg at the lowest O2 concentration possible.
The selected oxygen delivery system must maintain PaO2 at 55 to 60 mm Hg and SaO2 at 90% or greater at the lowest oxygen concentration possible.
You are admitting a 45-year-old asthmatic patient in acute respiratory distress. You auscultate the patient’s lungs and notice cessation of inspiratory wheezing. The patient has not yet received any medication. What does this finding suggest?
A. Spontaneous resolution of the acute asthma attack
B. An acute development of bilateral pleural effusions
C. Airway constriction requiring intensive interventions
D. Overworked intercostal muscles resulting in poor air exchange
C. Airway constriction requiring intensive interventions
When the patient in respiratory distress has inspiratory wheezing that ceases, it is an indication of airway obstruction, and it requires emergency action to restore the airway.
For which patient would NIPPV be an appropriate intervention to promote oxygenation
A. A patient’s whose cardiac output and blood pressure are unstable
B. A patient whose respiratory failure is caused by a head injury with loss of consciousness
C. A patient with a diagnosis of cystic fibrosis and who is producing copious secretions
D. A patient who is experiencing respiratory failure as a result of the progression of myasthenia gravis
D. A patient who is experiencing respiratory failure as a result of the progression of myasthenia gravis
NIPPV is most effective in treating patients with respiratory failure due to chest wall and neuromuscular disease. It is not recommended for patients who are experiencing cardiac instability, decreased level of consciousness, or excessive secretions.
You are aware of the value of using a mini-tracheostomy to facilitate suctioning when patients are unable to independently mobilize their secretions. For which patient is the use of a mini-tracheostomy 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
C. A patient whose increased secretions are the result of community-acquired pneumonia
It is probably appropriate to suction a patient with pneumonia using a mini-tracheostomy if blind suctioning is ineffective or difficult. An absent or compromised gag reflex, long-term ventilation, and a history of aspiration contraindicates the use of a mini-tracheostomy.
Which intervention is key to preventing ventilator-associated pneumonia as a complication in a patient with acute respiratory distress syndrome (ARDS)?
A. Scheduled prophylactic nasopharyngeal suctioning
B. Instilling normal saline down the endotracheal tube to loosen secretions
C. Providing frequent mouth care and oral hygiene
D. Using high tidal volumes on the ventilator
C. Providing frequent mouth care and oral hygiene
A frequent complication of ARDS is ventilator-associated pneumonia. Preventative strategies include elevating head-of-bed 30-45 degrees and strict infection control measures such as frequent hand washing, use of in-line suction, and frequent mouth care and oral hygiene. Suctioning is done only as needed to prevent stimulating excess secretions. Instilling normal saline does not loosen secretions and can cause hypoxia. It is not recommended. High tidal volumes can lead to barotrauma.
What pathophysiologic condition can result in ARDS?
A. Damage to the alveolar-capillary membrane
B. Copious exudates production
C. Airway spasms and vasoconstriction
D. Change in the inspiratory-to-expiratory ratio
A. Damage to the alveolar-capillary membrane
In ARDS, there is damage to the alveolar-capillary membrane, although the exact mechanism is not known. The damage results in increased pulmonary capillary membrane permeability, destruction of elastic and collagen, formation of pulmonary microemboli, and pulmonary artery vasoconstriction. These changes produce increased fluid accumulation and decreased lung compliance. Temporary narrowing of the airway is seen in asthma. Exudate production is seen with pneumonia or chronic obstructive pulmonary disease (COPD). The cause does not involve a change in ventilation, although there may eventually be some alteration due to respiratory distress.
Which is a classic finding for a patient with ARDS?
A. Hypoxemia despite increased oxygen administration
B. Bronchodilators ordered to relieve airway spasms
C. Development of Kussmaul respirations
D. Development of Cheyne-Stokes respirations
A. Hypoxemia despite increased oxygen administration
The hallmark of ARDS is hypoxemia despite increased FIO2 by mask, cannula, or endotracheal tube. Bronchodilators are used for asthma. Kussmaul respirations are caused by metabolic acidosis in diabetic ketoacidosis. Cheyne-Stokes respirations are a stairstep respiratory pattern with periods of apnea related to the body being stimulated by high CO2 levels to breathe. It is seen in patients with increased intracranial pressure.
Which is part of the nursing management for ARDS?
A. Aggressive use of intravenous (IV) fluids
B. Administration of a β-blocker
C. Use of positive end-expiratory pressure (PEEP)
D. Use of the lateral recumbent position
C. Use of positive end-expiratory pressure (PEEP)
In ARDS, higher levels of PEEP may be used. It increases the functional residual capacity (FRC) and opens collapsed alveoli. The issues in ARDS treatment are respiratory related, not fluid deficit. β-Blockers are part of myocardial infarction management, not ARDS. Some ARDS patients do better when placed in a prone position instead of a supine position. In the supine position, the heart places pressure on the pleural cavity. Changing the patient to a prone position allows air-filled, nonatelectatic alveoli in the ventral portion of the lung to become dependent.
A male patient’s X-ray result reveals bilateral white-outs, indicating adult respiratory distress syndrome (ARDS). This syndrome results from:
A. Cardiogenic pulmonary edema
B. Respiratory alkalosis
C. Increased pulmonary capillary permeability
D. Renal failure
C. Increased pulmonary capillary permeability
ARDS results from increased pulmonary capillary permeability, which leads to noncardiogenic pulmonary edema. In cardiogenic pulmonary edema, pulmonary congestion occurs secondary toheart failure. In the initial stage of ARDS, respiratory alkalosis may arise secondary to hyperventilation; however, it does not cause ARDS. Renal failure does not cause ARDS, either.
Nurse Oliver is caring for a client immediately after removal of the endotracheal tube. The nurse reports which of the following signs immediately if experienced by the client?
A. Stridor
B. Occasional pink-tinged sputum
C. A few basilar lung crackles on the right
D. Respiratory rate 24 breaths/min
A. Stridor
The nurse reports stridor to the physician immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway edema and places the client at risk for airway obstruction. Options B, C, and D are not signs that require immediate notification of the physician.
A nurse instructs a female client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to:
A. Promote oxygen intake
B. Strengthen the diaphragm
C. Strengthen the intercostal muscles
D. Promote carbon dioxide elimination
D. Promote carbon dioxide elimination
Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options A, B, and C are not the purposes of this type of breathing.
A nurse is caring for a male client with acute respiratory distress syndrome. Which of the following would the nurse expect to note in the client?
A. Pallor
B. Low arterial PaO2
C. Elevated arterial PaO2
D. Decreased respiratory rate
B. Low arterial PaO2
The earliest clinical sign of acute respiratory distress syndrome is an increased respiratory rate. Breathing becomes labored, and the client may exhibit air hunger, retractions, and cyanosis. Arterial blood gas analysis reveals increasing hypoxemia, with a PaO2 lower than 60 mm Hg.
A male adult client is suspected of having a pulmonary embolus. A nurse assesses the client, knowing that which of the following is a common clinical manifestation of pulmonary embolism?
A. Dyspnea
B. Bradypnea
C. Bradycardia
D. Decreased respirations
A. Dyspnea
The common clinical manifestations of pulmonary embolism are tachypnea, tachycardia, dyspnea, and chest pain.
A black client with asthma seeks emergency care for acute respiratory distress. Because of this client’s dark skin, the nurse should assess for cyanosis by inspecting the:
A. Lips.
B. Mucous membranes.
C. Nail beds.
D. Earlobes.
B. Mucous membranes.
Skin color doesn’t affect the mucous membranes. The lips, nail beds, and earlobes are less reliable indicators of cyanosis because they’re affected by skin color.
For a male client with an endotracheal (ET) tube, which nursing action is most essential?
A. Auscultating the lungs for bilateral breath sounds
B. Turning the client from side to side every 2 hours
C. Monitoring serial blood gas values every 4 hours
D. Providing frequent oral hygiene
A. Auscultating the lungs for bilateral breath sounds
For a client with an ET tube, the most important nursing action is auscultating the lungs regularly for bilateral breath sounds to ensure proper tube placement and effective oxygen delivery. Although the other options are appropriate for this client, they’re secondary to ensuring adequate oxygenation.
The nurse assesses a male client’s respiratory status. Which observation indicates that the client is experiencing difficulty breathing?
A. Diaphragmatic breathing
B. Use of accessory muscles
C. Pursed-lip breathing
D. Controlled breathing
B. Use of accessory muscles
The use of accessory muscles for respiration indicates the client is having difficulty breathing. Diaphragmatic and pursed-lip breathing are two controlled breathing techniques that help the client conserve energy.
A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis?
A. pH, 5.0; PaCO2 30 mm Hg
B. pH, 7.40; PaCO2 35 mm Hg
C. pH, 7.35; PaCO2 40 mm Hg
D. pH, 7.25; PaCO2 50 mm Hg
D. pH, 7.25; PaCO2 50 mm Hg
In respiratory acidosis, ABG analysis reveals an arterial pH below 7.35 and partial pressure of arterial carbon dioxide (PaCO2) above 45 mm Hg. Therefore, the combination of a pH value of 7.25 and a PaCO2 value of 50 mm Hg confirms respiratory acidosis. A pH value of 5.0 with a PaCO2 value of 30 mm Hg indicates respiratory alkalosis. Options B and C represent normal ABG values, reflecting normal gas exchange in the lungs.
A male client admitted to an acute care facility with pneumonia is receiving supplemental oxygen, 2 L/minute via nasal cannula. The client’s history includes chronic obstructive pulmonary disease (COPD) and coronary artery disease. Because of these history findings, the nurse closely monitors the oxygen flow and the client’s respiratory status. Which complication may arise if the client receives a high oxygen concentration?
A. Apnea
B. Anginal pain
C. Respiratory alkalosis
D. Metabolic acidosis
A. Apnea
Hypoxia is the main breathing stimulus for a client with COPD. Excessive oxygen administration may lead to apnea by removing that stimulus. Anginal pain results from a reduced myocardial oxygen supply. A client with COPD may have anginal pain from generalized vasoconstriction secondary to hypoxia; however, administering oxygen at any concentration dilates blood vessels, easing anginal pain. Respiratory alkalosis results from alveolar hyperventilation, not excessive oxygen administration. In a client with COPD, high oxygen concentrations decrease the ventilatory drive, leading to respiratory acidosis, not alkalosis. High oxygen concentrations don’t cause metabolic acidosis.
Which of the following are early s/sx of ARDS?
A. Retractions - not always (tissues between ribs and above sternum pull in) B. Dyspneic C. Non-productive cough D. Accessory muscle used E. Pallor or cyanosis F. Significant CXR changes; pulmonary infiltrates G. Restlessness H. CXR clear I. Respiratory alkalosis J. Respiratory acidosis
B. Dyspneic C. Non-productive cough E. Pallor or cyanosis G. Restlessness H. CXR clear I. Respiratory alkalosis
A patient is diagnosed with a large pulmonary embolism. When explaining to the patient what has happened to cause respiratory failure, which information will the nurse include?
a. “Oxygen transfer into your blood is slow because of thick membranes between the small air sacs and the lung circulation.”
b. “Thick secretions in your small airways are blocking air from moving into the small air sacs in your lungs.”
c. “Large areas of your lungs are getting good blood flow but are not receiving enough air to fill the small air sacs.”
d. “Blood flow though some areas of your lungs is decreased even though you are taking adequate breaths.”
d. “Blood flow though some areas of your lungs is decreased even though you are taking adequate breaths.”
A pulmonary embolus limits blood flow but does not affect ventilation, leading to a ventilation-perfusion mismatch. The response beginning, “Oxygen transfer into your blood is slow because of thick membranes” describes a diffusion problem. The remaining two responses describe ventilation-perfusion mismatch with adequate blood flow but poor ventilation.
A patient is brought to the emergency department unconscious following a barbiturate overdose. Which potential complication will the nurse include when developing the plan of care?
a. Hypercapnic respiratory failure related to decreased ventilatory effort
b. Hypoxemic respiratory failure related to diffusion limitations
c. Hypoxemic respiratory failure related to shunting of blood
d. Hypercapnic respiratory failure related to increased airway resistance
a. Hypercapnic respiratory failure related to decreased ventilatory effort
The patient with an opioid overdose develops hypercapnic respiratory failure as a result of the decrease in respiratory rate and depth. Diffusion limitations, blood shunting, and increased airway resistance are not the primary pathophysiology causing the respiratory failure.
A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department complaining of acute respiratory distress. When monitoring the patient, which assessment by the nurse will be of most concern?
a. The patient is sitting in the tripod position.
b. The patient has bibasilar lung crackles.
c. The patient’s pulse oximetry indicates an O2 saturation of 91%.
d. The patient’s respiratory rate has decreased from 30 to 10/min.
d. The patient’s respiratory rate has decreased from 30 to 10/min.
A decrease in respiratory rate in a patient with respiratory distress suggests the onset of fatigue and a high risk for respiratory arrest; therefore, the nurse will need to take immediate action. 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
A finding indicating to the nurse that a 22-year-old patient with respiratory distress is in acute respiratory failure includes a
a. shallow breathing pattern.
b. partial pressure of arterial oxygen (PaO2) of 45 mm Hg.
c. partial pressure of carbon dioxide in arterial gas (PaCO2) of 34 mm Hg.
d. respiratory rate of 32/min.
b. partial pressure of arterial oxygen (PaO2) of 45 mm Hg.
The PaO2 indicates severe hypoxemia and that the nurse should take immediate action to correct this problem. Shallow breathing, rapid respiratory rate, and low PaCO2 can be caused by other factors, such as anxiety or pain.
While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient’s arterial oxyhemoglobin saturation (SpO2) from 94% to 88%. The nurse will
a. assist the patient to cough and deep-breathe.
b. help the patient to sit in a more upright position.
c. suction the patient’s oropharynx.
d. increase the oxygen flow rate
d. increase the oxygen flow rate
Increasing oxygen flow rate will usually 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.
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 high-Fowler’s position.
d. in the tripod position.
b. on the right side
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.
