The Respiratory System

Question 1

Ventilation

Answer 1

air movement in and out of the lungs

Question 2

Oxygenation

Answer 2

oxygen perfused into the bloodstream

Question 3

Perfusion

Answer 3

Oxygen delivery to the tissues

Question 4

Stridor

Answer 4

Continuous, high pitched; crowing sound heard predominantly on inspiration; cause of sound is generally tracheal/larynx obstruction. It may be heard in croup or airway obstruction.

Question 5

Wheeze

Answer 5

high-pitched; continuous; caused by air passing through obstructed/narrowed airway.

Question 6

Rhonchi

Answer 6

sonorous wheeze; deep-low-pitched rumbling or coarse air sounds as air moved through tracheal/bronchial passages in the presence of mucous/secretions; commonly heard during expiration

Question 7

Crackles

Answer 7

AKA “Alveolar Rales”; caused by air passing through fluid or pus or mucous; coarse: low-pitched, moist, pulmonary edema or bronchitis; fine: sounds like hair rubbing on ear; occurs with CHF or pulmonary fibrosis.

Question 8

Increased work of breathing

Answer 8

substernal retractions
nasal flaring
accessory muscle use
grunting
belly breathing
tripod positioning

Question 9

how many litres does a nasal cannula deliver?

Answer 9

0-6L

Question 10

how many litres does a simple face mask deliver

Answer 10

6-10L

Question 11

how many litres does a non-rebreather deliver

Answer 11

0-15L/min (make sure rebreather is full)

Question 12

FiO2

Answer 12

percentage of inspired oxygen
room air is 21%
Optiflow can deliver up to 100% FiO2

Question 13

Endotracheal Intubation

Answer 13

invasive artificial airway used when the patient is unable to protect their own airway; plastic tube is inserted into the trachea; maintains airway to deliver oxygen to the lungs; placement is verified with x-ray; assess bilateral lung sounds because it can displace into the right bronchus.

Question 14

Tracheostomy

Answer 14

artificial airway used for long-term needs; used for obstruction, slow ventilation weaning, tracheal damage, and neuromuscular damage.

Question 15

Reasons for high pressure alert alarm on mechanical ventilator machine

Answer 15

• coughing
• gagging
• bronchospasm
• fighting the ventilator
• kink or occlusion
• secretions
• water in circuit

Question 16

Reasons for low pressure alert alarm on mechanical ventilator machine

Answer 16

• tubing disconnected
• loose connection
• leak
• extubation
• deflated trach cuff
• poor fitting mask

Question 17

CPAP

Answer 17

continuous positive airway pressure; delivers air at a single set pressure; not as good as BIPAP at detecting or accommodating breathing; recommended for obstructive sleep apnea

Question 18

BiPAP

Answer 18

bi-level positive airway pressure; delivers at two different pressure settings for inspiration and expiration; indicated for central sleep apnea, neuro/heart/airway diseases; pressure helps keep alveoli open.

Question 19

chest tubes

Answer 19

inserted into the pleural space to remove fluid/air that caused the lung to collapse; used after cardiac surgery
Indications: pneumothorax, pleural effusions; abcèss; cancer; hemothorax
Nursing Considerations: always keep drainage system below the heart; ensure tubing is kink free and draining freely, avoid dependent leaks, system goes in biohazard garbage.
Monitor Drainage: color, odour, consistency, amount (no more than 100cc/hr –> mark hourly)
Dislodgement: cover with sterile, vaseline impregnated or occlusive dressing with tape on three sides, allowing air to escape but prevents air from entering; stays with client; call MRP; use call light and request additional support; airway support

Question 20

Albuterol

Answer 20

Pharm Class: bronchodilator; SABA
Indications: asthma, COPD
Action: binds to beta 2 receptors in the airway, leading to relaxation of smooth muscle
Considerations: caution with HF, DM, glaucoma, and seizures; causes tachycardia.

Question 21

Terbutaline

Answer 21

Therapeutic Class: Selective B2AA
Action: binds to beta 2 receptors in the airway to cause bronchodilator by inhibiting the release of hypersensitivity reaction products from mast cells.
Indications: relief and maintenance of wheezing, SOB, and coughing caused by asthma.
Considerations: shakiness, jitteriness, dizziness, sleep disturbances, weakness, headache, N/V, tachycardia, hyperglycemias, CNS overstimulation may occur. Assess BP. HR. ECG. and BG. Available in PO/SC/MDI with 4-6hr duration. Teach MDI use.

Question 22

Methylprednisolone

Answer 22

Pharm Class: Steroid
Indications: inflammation, allergy, autoimmune diseases
Action: suppresses immune system, suppressing inflammation and normal immune response
Considerations: monitor for too much steroids; Cushing’s syndrome; buffalo hump.
Side Effects: immunosuppression, hyperglycemias, osteoporosis, delayed wound healing.

Question 23

H-1 Receptor Blocker

Answer 23

Blocks H-1 receptors in the CNS, which stops allergy reactions.

Question 24

Diphenhydramine

Answer 24

Pharm Class: H-1 receptor Blocker
Indication: allergy; anaphylaxis; sedation
Action: antagonizes effects of histamine and causes CNS depression.
Considerations: monitor for drowsiness, anticholinergic effects (dry mouth, slow speech, urinary retention, etc)

Question 25

H-2 Receptor Blocker

Answer 25

blocks production of stomach acid
drugs: ranitidine, famotidine.

Question 26

COPD

Answer 26

a group of lung diseases that block airflow and make it difficult to breathe

Question 27

Emphysema

Answer 27

destruction of the alveoli due to chronic inflammation; decreased surface area results, leading to impaired gas exchange

Question 28

Chronic Bronchitis

Answer 28

chronic inflammation of the airway with productive cough, and increasing sputum.

Question 29

Asthma

Answer 29

respiratory disease with bronchospasm in the bronchi and chronic inflammation of the airway resulting in excessive mucous production. Damage is irreversible.

Question 30

Treatment for Asthma

Answer 30

Short Term:
1. Airway: intubate; adrenergic agonists (albuterol)
2. Breathing: Oxygen, theophylline, ipratropium, dexamethasone
3. Circulation: IV fluids
Long Term:
- Inhaled corticosteroids (Budenoside, fluticasone daily)
- Leukotreine modifiers [Montelukast (blocks leukotrienes from overresponse to triggers); Theophylline (bronchodilator; must be used regularly); allergy control (clean environment; avoid triggers)

Question 31

Complications of Asthma

Answer 31

• Status Asthmaticus
• Pneumonia
• ARDS
• Pulmonary Embolism

Question 32

Status Asthmaticus

Answer 32

asthma attack that is refractory to treatment; leads to respiratory failure; can progress to death if untreated
Treatment:
- bronchodilators
- chest physio
- increased fluid intake
- pursed lip breathing
- eat small, frequent meals
- avoid abdominal distension
Considerations: be careful with O2 administration; hypercarbia stimulates breathing and if you hyper oxygenate the patient, breathing may stop.

Question 33

Pneumonia

Answer 33

inflammation of the lung that impacts the alveoli; alveoli become filled with pus and liquid
Types:
- Viral – RSV, adenovirus, influenza
- Bacterial
- fungal
- chemical
- aspiration
Diagnosis: chest x-ray – patchy infiltrates and sputum culture
S & S: fever, cough, tachypnea, crackles, chest pain, increased WOB
Treatment:
airway suctioning and spo2 monitoring; breathing assessment (WOB, humid O2), monitor for dehydration, give IV fluids, chest physio, antipyretics, analgesia, expectorants, antibiotics, isolation precautions (droplet for three days).

Question 34

ARDS

Answer 34

acute condition characterized by bilateral pulmonary infiltration and severe hypoxemia in the absence of cariogenic pulmonary edema. Fluid collects in the alveoli and deprives the body of oxygen.
Causes: Sepsis, trauma, COVID, burns, aspiration, OD, and near drowning.
Assessment: chest x-ray – will show diffuse, bilateral infiltrates; Hypoxemia (pale, cool, dusky mottled skin with low spo2)
Treatment: intubation (mechanical ventilation with high pressures); prone positioning; prevent infection.

Question 35

Pulmonary Embolism

Answer 35

life-threatening blood clot in the lungs; caused by embolism in vein or clot during surgery; the clot decreases tissue perfusion, causing hypoxemia; can lead to right-sided heart failure if untreated
S & S: anxiety, dyspnea, chest pain, hypoxemia, rales, diaphoresis, hemoptysis.
Treatment: O2, high fowlers, heparin, ACE inhibitors.

Question 36

Oxygen Treatment for Carbon Monoxide Poisoning

Answer 36

CO poisoning requires aggressive oxygenation at a FiO2 of 100%. A nonrebreather is the only delivery device to provide a FiO2 level of 100% and is used for a client with CO poisoning.
✓ Carbon monoxide binds to a red blood cell approximately 200x more than oxygen

✓ Carbon monoxide poisoning may occur from smoke inhalation from fires, poorly functioning heating systems, and motorboat and motor vehicle exhaust exposure in a closed setting

✓ Manifestations include headache, dizziness, weakness, malaise, altered mental status, and visual changes

✓ This poisoning is tasteless, odorless, and colorless

✓ Treatment includes removing the client from the source of the poison, putting them outside, calling EMS, and administering 100% high-flow oxygen

Question 37

Legionnaires Disease

Answer 37

a severe form of pneumonia and lung inflammation caused by infection known as legionella.

Question 38

sequence for suctioning tracheostomy tube

Answer 38

irst, the nurse will perform hand hygiene and identify the patient.

Second, hyper-oxygenate the patient to prepare them for the procedure and prevent desaturations.

Third, insert the suction catheter without suctioning to the pre-measured depth. The nurse should be sure to not allow the suction catheter to touch anywhere other than the inside of the tracheostomy. It is recommended to insert the suction catheter with the nondominant hand.

Fourth, apply intermittent suction and rotate the suction catheter as you remove it from the tracheostomy. The nurse should ensure the suctioning does not exceed 10 seconds.

Lastly fifth, replace the cap, mist collar, oxygen mask, or other apparatus to the tracheostomy and monitor the patient to ensure they return to baseline.

Question 39

Trach care considerations

Answer 39

• assess respiratory status, trach ties, skin integrity, and need for suctioning
• set up sterile field then remove and clean the inner cannula. If disposable, replace with new one.
• cleanse stoma site, then tracheostomy plate, ensuring no fluids enter.
• replace ties if soiled; secure before removing old ties; one finger width
• document amount of secretions, appearance of stoma and surrounding skin, and the client’s response.

Question 40

carbon monoxide poisoning

Answer 40

CO poisoning is odorless, colorless, and tasteless. This potentially lethal poison initially causes clients to develop symptoms such as headache, reduced visual acuity, and slight breathlessness. As the CO level increases, it causes hypotension, confusion, and vertigo and then progresses to death.
A common misconception about CO poisoning is that it causes a decrease in SpO2. This is not accurate because pulse oximetry does not differentiate COHb from oxyhemoglobin. It is entirely plausible and likely that the client has a normal SpO2. CO poisoning would not cause hyperarousal. Instead, it would cause the client to experience dizziness and lethargy. Tachycardia is commonly seen as a compensatory mechanism from the falling cardiac output, not bradycardia.
✓ Carbon monoxide binds to a red blood cell approximately 200x more than oxygen

✓ Carbon monoxide poisoning may occur from smoke inhalation from fires, poorly functioning heating systems, and motorboat and motor vehicle exhaust exposure in a closed setting

✓ Manifestations include headache, dizziness, weakness, malaise, altered mental status, and visual changes

✓ This poisoning is tasteless, odorless, and colorless

✓ Treatment includes removing the client from the source of the poison, putting them outside, calling EMS, and administering 100% high-flow oxygen

Question 41

disorder closely associated with cystic fibrosis

Answer 41

Diabetes mellitus is a common co-morbidity associated with cystic fibrosis (CF). The damage that CF may cause to the pancreas may induce diabetes. Thus, random blood glucose levels and quarterly hemoglobin A1C levels are commonly ordered throughout the course of the illness. A random blood glucose level greater than 200 mg/dL may suggest the presence of diabetes.
Complications Associated
with Cystic Fibrosis
* Pneumonia
Pneumothorax
Diabetes mellitus
Depression
* Failure to thrive
* Vitamin deficiencies
Osteoporosis
* Pancreatitis
Infertility

Question 42

What findings represent a pneumothorax?

Answer 42

A pneumothorax has clinical features such as reduced breath sounds on the affected sides, tachypnea, dyspnea, and pleuritic chest pain. Some clients may be asymptomatic, depending on the size of the pneumothorax.
Pneumothorax may be caused by trauma to the chest wall secondary to a traumatic injury. Pneumothorax may also adversely develop during the placement of a subclavian or intrajugular central line. The priority treatment for clients unstable with pneumothorax is the placement of a chest tube.

Question 43

complications of endotracheal suctioning

Answer 43

Tracheal suctioning is often needed to clear the secretions and maintain an open airway. It is important for the RN to understand the complications of tracheal suctioning. If the nurse notices a change in vital signs (tachycardia, tachypnea) while suctioning a patient, the nurse should stop the suctioning and check the oxygen saturation immediately. When the client becomes tachycardic and tachypneic while suctioning, it is a sign of distress which indicates that the client is not tolerating the suctioning. Hence, suctioning needs to be immediately discontinued to prevent further distress and the cause of the distress should be explored. Hypoxemia is an important cause of tachycardia and cardiac arrhythmias during suctioning. If hypoxemia is noted, 100% oxygen should be administered quickly. Other things to monitor for would be bradycardia, changes in the heart rhythm (arrhythmias), desaturations, or cyanosis.

Question 44

cause of mucous plugging

Answer 44

Mucus plugging is caused by slowed smooth muscle contraction brought about by bradykinin, not histamine.

Question 45

Which bodily reactions is histamine responsible for??

Answer 45

Erythema, tissue swelling, and shock are caused by the dilation of blood vessels and increased vascular permeability brought about by histamine. Shortness of breath and wheezing are caused by the constriction of smooth muscles in the bronchial airways brought about by histamine. Histamine release over-stimulates the nerve endings causing itchiness and painful skin.

Question 46

Endotracheal Tube Considerations

Answer 46

When a client is intubated via ETT, the initial verification methods include a chest x-ray and end-tidal carbon dioxide (EtCO2). A chest x-ray will verify that the tube terminates 2-3 cm above the carina. End-tidal carbon dioxide (EtCO2) monitoring is a device that may be added and typically changes color when the tube is in the appropriate place. End-tidal carbon dioxide ranges between 20 and 40 mm Hg.
✓ When a client is being mechanically ventilated, airway patency is the priority.
✓ A bag-valve mask should be readily available during a power failure or emergency resuscitation.
✓ Review ventilator settings frequently and collaborate with respiratory therapy to assist in ventilator management.
✓ The client’s head of the bed should be more than 30 degrees when supine to decrease the risk for aspiration and ventilator-associated pneumonia (VAP).
✓ VAP can be prevented by
Oral care using an antiseptic
Minimizing exposure to proton pump inhibitors
Meticulous hand hygiene by nursing staff/visitors
Pulmonary hygiene measures such as chest physiotherapy
When caring for a client on a ventilator, you should be familiar with the following settings:
Mode (Volume [SIMV, A/C] or Pressure [PSV])
Rate (Number of breaths per minute)
Tidal volume (the amount of gas delivered to the client)
Fraction of inspired oxygen (FiO2 - the percentage of oxygen given per breath)
PEEP (pressure added at exhalation to keep the small airways open and mitigate atelectasis)
Pressure support (PS - provides added pressure when the client takes a spontaneous breath)

Question 47

Why is airway patency the priority for assessing a 76 year old with pneumonia?

Answer 47

Impaired mobility in older adults creates a risk for airway collapse, reduced air exchange, hypoxia, hypercapnia, and acidosis. Reduced gag and cough reflexes can place older people at risk for aspiration of secretions and, potentially, aspiration pneumonia. There is a possibility of postoperative respiratory complications because of impaired cough reflex, weaker muscles, and decreased inspiratory capacity. Older adults are at increased risk of respiratory complications due to stress. The nurse should pay attention to maintaining adequate ventilation, keeping lung volumes high, clearing secretions, and positioning to prevent aspiration.

Question 48

Where are bronchovesicular sounds best heard?

Answer 48

Bronchovesicular sounds occur over major bronchi where there are fewer alveoli. They are moderate in pitch and amplitude and are normally equal during inspiration and expiration. Posteriorly, bronchovesicular breath sounds can be auscultated between the scapulae.

Question 49

Respiratory sounds associated with pulmonary congestion

Answer 49

Crackles and rales are indicative of pulmonary congestion. Because this child has coarctation of the aorta, there is too much blood backing up in the lungs. It is impossible for the left side of the heart to move sufficient blood forward working against the coarctation. This causes the back up of blood in the lungs, and therefore the crackles and rales are indicative of pulmonary congestion.

Question 50

why should you never deflate the cuff of a tracheostomy or unneededly manipulate the insertion site following tracheostomy insertion?

Answer 50

In the absence of an emergency, the cuff should never be deflated during the initial 24-hour period. In order to minimize the risk of bleeding around the insertion site for the initial 24 hours following a tracheostomy, the nurse must minimize the number of tracheostomy manipulations that occur. Each time a tracheostomy tube is manipulated, there is an opportunity for complications and associated morbidity. Every manipulation carries the risk of trauma to the tracheostomy wound and accidental decannulation.
Tracheostomies are common surgical procedures used for long-term airway management that involves creating a permanent connection between the anterior neck and trachea.
Indications include upper airway obstruction, prolonged mechanical ventilation, long-term management of secretions, severe obstructive sleep apnea, and/or head/neck surgery.
Tracheostomies are placed inferior to the cricothyroid membrane, most commonly between the second and third tracheal rings.
For mechanically ventilated clients, tracheostomies generally occur between days 7 and 21 of mechanical ventilation.

Question 51

High pressure ventilation alarm

Answer 51

The high-pressure alarm signifies an obstruction in the tubing caused by the client biting on the tube or secretions in the ETT. The nurse should assess the client to determine if they are in pain as the prescribed propofol is not pain medication. If pain is not the cause of the alarm, the nurse should assess the client for the need to be suctioned. Tachypnea decreased oxygen saturation, and rhonchi in the lung fields would support the need for the client to be suctioned.

The low-pressure alarm may indicate that the client has extubated themselves, disconnected from the ventilator, or has low cuff pressure.
Ventilator alarms should always be enabled to alert the nurse of potential complications. The first action the nurse should take when responding to an alarm is to assess the client. Essential items to have at the bedside while a client is mechanically ventilated are a bag-valve mask and oxygen.

Question 52

Trach safety equipment at bedside at all times

Answer 52

When caring for a client with a tracheostomy, the nurse should have the necessary safety equipment at the bedside, and this includes –
Two extra inner cannulas - one fitting the client and one smaller size.
Obturator
Suction equipment
Oxygen source/tank

Question 53

You are caring for a newly admitted obese patient in the ICU. The patient has a history of smoking. She states that her symptoms started early in life and are worse at night. She denies any history of recent fever or chills. You notice wheezing and stridor upon assessment. You expect the diagnosis for this patient will be:

A. Asthma
B. Bronchiectasis
C. Congestive heart failure (CHF)
D. Chronic obstructive pulmonary disease (COPD)

Answer 53

Asthma typically begins in early life, whereas symptoms of CHF and COPD usually develop later in life. Bronchiectasis typically presents with signs and symptoms of a recent infection, including large amounts of bronchial secretions. Asthma symptoms tend to come and go with symptoms being worse at night. There is often a family history of asthma, and it usually occurs in obese patients.

Question 54

The nurse is taking vital signs for a client who has a chest tube in place. While counting the client’s respirations, the nurse notes that the water in the water-seal-chamber is fluctuating. Which action by the nurse is most appropriate based on this finding?

Answer 54

t is appropriate for the nurse to finish counting the client’s respirations and continue to monitor them as normal. Fluctuations of water in the water-seal chamber with inspiration and expiration are a sign that the drainage system is patent. Normally, the water level will increase when the client breathes in, and then decrease when they breathe out. This is due to changes in intrathoracic pressures.

Question 55

Formoterol

Answer 55

Formoterol is a maintenance medication indicated for asthma. Fometerol is a long-acting bronchodilator and would not help treat acute laryngotracheobronchitis.

Question 56

Albuterol

Answer 56

Albuterol is a short-acting bronchodilator. It is used as a rescue inhaler and is helpful in acute asthma attacks. In croup, the upper airways are edematous and inflamed, causing stridor and airway obstruction. Albuterol is not beneficial in the management of croup because it does not target the upper airways.

Question 57

Montelukast

Answer 57

Montelukast is a leukotriene inhibitor. It is given two hours before exercise to prevent/ reduce the symptoms of exercise-induced asthma.

Question 58

Croup

Answer 58

✓ Croup (laryngotracheitis and laryngotracheobronchitis) is commonly caused by a viral infection (influenza types A and B, adenovirus, RSV, and measles) that is slowly progressive

✓ It typically features a brassy (barking) cough, hoarseness, restlessness because of the frequent coughing, low-grade fever, and inspiratory stridor. The inflammation and swelling of the upper airways result in stridor. In severe croup, the child should be evaluated very carefully not to cause any additional discomfort because any increase in agitation or crying can further worsen the airway narrowing.

✓ Treatment is with corticosteroids, fluids, and nebulized epinephrine in severe cases

Question 59

Aspiration Pneumonitis

Answer 59

✓ Aspiration pneumonitis and pneumonia are caused by inhaling toxic and/or irritant substances, most commonly large volumes of upper airway secretions or gastric contents, into the lungs

✓ Symptoms include cough and dyspnea

✓ Diagnosis is based on clinical presentation and chest x-ray findings

✓ Treatment and prognosis differ by aspirated substance

✓ The term “aspiration pneumonia” is used when the ability to protect the lower airway is compromised and/or a large volume is aspirated

Question 60

ARDS

Answer 60

✓ An array of conditions, including pneumonia, may cause acute respiratory distress syndrome (ARDS)

✓ ARDS is classically manifested by hypoxemia despite the client receiving supplemental oxygen

✓ ARDS causes pulmonary edema, infiltrates, decreased compliance, and hypoxemia (despite supplemental oxygen)

✓ Early recognition is key to survival, and an indicator of ARDS is refractory hypoxemia

✓ Treatment is oxygenation and potentially mechanical ventilation via an endotracheal tube (ETT)

✓ Manifestations of ARDS include hypoxemia despite receiving supplemental oxygen, tachycardia, restlessness, respiratory alkalosis, which transitions to acidosis if untreated

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Question 61

A 32-year-old man comes into the emergency department after being hit by a baseball bat in his chest. The nurse would suspect a pneumothorax because of which sign?

Answer 61

A client who experiences a pneumothorax may initially experience shortness of breath and chest pain. When the pneumothorax increases in size the client will display an increased respiratory rate, cyanosis, diminished breath sounds, and subcutaneous emphysema.

Question 62

The nurse cares for a client receiving mechanical ventilation who is prescribed one unit of packed red blood cells to be transfused. Which finding would alert the nurse of a transfusion-related reaction?

A. Low-pressure alarm
B. Increased blood glucose
C. Diminished lung sounds
D. Hemoglobinuria

Answer 62

Hemoglobinuria is a classic manifestation associated with a hemolytic reaction. The hemolysis caused by incompatible blood is caused the body to spill hemoglobin in the urine. If this is assessed, the nurse should stop the transfusion, disconnect the tubing, and infuse isotonic saline. The tubing and unit of blood should be returned to the blood bank. Finally, a urine analysis should be obtained to confirm this finding.
✓ For the unconscious client (or the client receiving mechanical ventilation), the nurse must use expert skills to determine the presence of a transfusion reaction

✓ Weak pulse, fever, tachycardia or bradycardia, hypotension, visible hemoglobinuria, oliguria, or anuria are manifestations associated with a reaction

Question 63

Bronchoscopy

Answer 63

A bronchoscopy is a procedure used to examine the lungs and collect tissue samples for biopsy. Although rare, a pneumothorax does occur in 2-5% of post-transbronchial biopsy clients. Manifestations of this complication may include dyspnea, tachypnea, tachycardia, and coughing. The nurse should not feed the client until the gag reflex has returned.

Question 64

Which percussion sound would indicate further assessment is needed?

A. Dull tone over the spleen
B. Hyperressonance over an adult’s lung tissue
C. Flat tone over bone
D. Hyperressonance over a child’s lung tissue

Answer 64

Hyperressonance is an abnormal finding over adult lung tissue. It indicates an abnormal increase in the amount of air present, such as with emphysema.