ch36.doc

[Osborn] chapter 36

Learning Outcomes [Number and Title] Learning Outcome 1 Describe the etiology, incidence, and types of acute respiratory

failure as seen by nurses in acute care settings.Learning Outcome 2 Define pulmonary edema and state three of the common

etiologies of pulmonary edema that are seen in practice.Learning Outcome 3 Differentiate between noncardiogenic pulmonary edema and

cardiogenic pulmonary edema, as it relates to patient symptomology.

Learning Outcome 4 Distinguish between acute respiratory distress syndrome (ARDS) and acute lung injury (ALI) in patients presenting in an acute care setting.

Learning Outcome 5 Identify the common ventilator modes and important nursing implications for each mode.

Learning Outcome 6 Define PEEP and state two complications of this therapy.Learning Outcome 7 List the equipment needed for intubation, and explain how the

equipment is used with a patient.Learning Outcome 8 Review the procedure for suctioning and state two important

nursing implications related to conducting this procedure. Learning Outcome 9 State two indications for insertion of a chest tube in a patient in

an acute care setting.

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for Practice Copyright 2010 by Pearson Education, Inc.

1. The client presents with PaO2 of 54 mmHg and an arterial oxygen saturation of 80%. The nurse recognizes that which of the following is the most likely cause for this type of acute respiratory failure?

1. Pneumothorax2. Oversedation3. Cervical spinal cord injury4. Obesity

Correct Answer: Pneumothorax

Rationale: A PaO2 of 54 mmHg and an arterial oxygen saturation of 80% are indicative of hypoxemic respiratory failure and can be caused by conditions that would lower the oxygen content of the client. In this instance, a pneumothorax would likely be the cause. Oversedation and obesity are likely causes of hypercapnia respiratory failure. Cervical spinal cord injury would result in the central nervous system as a cause.

Cognitive Level: ApplicationNursing Process: PlanningClient Need: Physiological IntegrityLO: 1


2. An obese postoperative client without known respiratory or central nervous system disease is unable to be extubated in the postanesthesia recovery unit due to abnormal ABG results. The client does not respond to the nurse’s commands and has a respiratory rate of 10. What ABG results might the nurse expect?

1. pH – 7.28; PaO2 of 80 mmHg; paCO2 55 mmHg; HCO3 22 mmHg; SaO2 92%2. pH – 7.35; PaO2 of 58 mmHg; paCO2 36 mmHg; HCO3 25 mmHg; SaO2 85%3. pH – 7.42; PaO2 of 52 mmHg; paCO2 45 mmHg; HCO3 26 mmHg; SaO2 82%4. pH – 7.44; PaO2 of 59 mmHg; paCO2 50 mmHg; HCO3 25 mmHg; SaO2 89%

Correct Answer: pH – 7.28; PaO2 of 80 mmHg; paCO2 55 mmHg; HCO3 22 mmHg; SaO2

92%

Rationale: The nurse would expect the oversedated, nonresponsive client to potentially have hypercapnia resulting from the residual of intraoperative medications and the inability to rid him- or herself of CO2. The other ABG results would indicate hypoxemic respiratory failure, an unlikely finding since the client had no prior respiratory history.

Cognitive Level: AnalysisNursing Process: AssessmentClient Need: Physiological IntegrityLO: 1


3. A client presents to the emergency department complaining of sudden onset of increased weakness and tingling of the lower extremities that has progressed to the upper arms. The client is diagnosed with Guillain-Barre. The client’s respiratory rate is 8; blood pressure is 86/48. The client is being prepared for intubation. What would the nurse anticipate the blood gases to be?

1. High PaCO2

2. Low PaCO2

3. High HCO3

4. High pH

Correct Answer: High PaCO2

Rationale: The nurse would anticipate the client with progressing Guillain-Barre to have hypoventilation, which results in high PaCO2 levels. The respiratory rate of 8 also would indicate hypoventilation. The nurse would also anticipate the pH to be low (acidic), not high, since a high level of CO2 will increase the acidity of the blood. A low PaCO2 results with tachypnea, which this client does not have. A low PaCO2, high HCO3, and high pH are all alkolotic states.



4. A client presents to the emergency department (ED) with symptoms of pulmonary edema. It is important for the ED nurse to determine which of the following as part of the client’s history?

1. Cardiac and pulmonary history2. Renal and cardiac history3. Pulmonary and renal history4. Recent drug use and past vaccination record

Correct Answer: Cardiac and pulmonary history

Rationale: Attempting to determine a cause for pulmonary edema will assist the health care team in providing appropriate care. Cardiogenic and noncardiogenic pulmonary edemas have different approaches to treatment. The renal history will be addressed, but is not a priority assessment when the client first comes to the ED. Recent drug use and past vaccination record will be details the nurse will ask during the admission process, but are not important data initially in the ED when presenting with pulmonary edema.

Cognitive Level: ApplicationNursing Process: AssessmentClient Need: Physiological IntegrityLO: 2


5. A 70-year-old client presents to the clinic with acute onset of dyspnea and increased respiratory secretions. The health care provider diagnoses the client with pulmonary edema. The family asks the nurse what that means. The nurse correctly states that pulmonary edema:

1. “Is too much fluid in the lungs.”2. “Is a narrowing of the coronary vessels that causes the heart to stop working

correctly.”3. “Rarely affects individuals older than 60.”4. “Is caused by a person’s excessive working when younger.”

Correct Answer: “Is too much fluid in the lungs.”

Rationale: Pulmonary edema is the accumulation of excess fluid in the lungs caused by cardiac and noncardiac factors. Heart failure is often seen in individuals older than 65 and is a common cause of pulmonary edema in elders. There is no evidence that pulmonary edema is related to an individual’s work history when younger. A narrowing of the coronary vessels (i.e., a potential heart attack) could contribute to heart failure, which could cause pulmonary edema, but there is no evidence from the question that this is the cause.

Cognitive Level: ApplicationNursing Process: ImplementationClient Need: Physiological IntegrityLO: 2


6. A client was admitted 3 days ago with a myocardial infarction and has developed pulmonary edema. The family is asking the nurse about the cause of pulmonary edema. The nurse shares with the family which of the following best explanations?

1. The cardiac muscle has been injured and is not able to efficiently pump the blood through the client’s system, resulting in an increased pressure in the pulmonary system.

2. The pulmonary system was injured first due to hypoxia, which caused the heart attack.

3. The cardiac muscle is working too hard to push fluids through the pulmonary system and there is fluid excess as a result.

4. The pulmonary system has an excessive amount of fluid that has been building over the last several days and now the heart is no longer able to keep up with the demands.

Correct Answer: The cardiac muscle has been injured and is not able to efficiently pump the blood through the client’s system, resulting in an increased pressure in the pulmonary system.

Rationale: During an MI, the cardiac muscle is injured and is not able to efficiently pump blood through the system. This decrease in pumping action results in an increased pulmonary pressure, which causes fluid to fill the interstitial spaces. The other explanations are not correct because the pulmonary system did not cause the MI, the MI causes pulmonary edema; it is not that the cardiac muscle is working too hard, but instead it is not working as well as it used to; and the pulmonary fluid overload is a direct result of the MI, not building up over several days.

Cognitive Level: AnalysisNursing Process: ImplementationClient Need: Physiological IntegrityLO: 2


7. The nurse is giving a report to the oncoming ICU shift for the most recent admission. The nurse indicates the client is hypotensive, has an S3 heart sound, has crackles, has pink frothy sputum, and the skin is diaphoretic and cool. The oncoming shift recognizes the differences between cardiogenic pulmonary edema (CPE) and noncardiogenic pulmonary edema (NCPE) as:

1. CPE clients will be hypotensive, have an S3 heart sound, and be cool and diaphoretic.

2. NCPE clients will be hypotensive, have an S3 heart sound, and have a cough.3. CPE clients will be hypotensive, have an S3 heart sound, and have bounding

pulses.4. NCPE clients will be hypertensive, have bounding pulses, and have jugular

vein distension.

Correct Answer: CPE clients will be hypotensive, have an S3 heart sound, and be cool and diaphoretic.

Rationale: This client has CPE, as evidenced by the symptoms of hypotension, an S3 heart sound, and being cool and diaphoretic. Crackles and pink frothy sputum are found in both CPE and NCPE. NCPE clients will have hypertension, bounding pulses, and will be warm and dry.



8. An ICU nurse has been taking care of a septic client. The client suddenly develops dyspnea, crackles, hypertension, bounding pulses, agitation, and confusion. The nurse recognizes these are symptoms of:

1. Noncardiogenic pulmonary edema.2. Right-sided heart failure.3. Left-sided heart failure.4. Constrictive pericarditis.

Correct Answer: Noncardiogenic pulmonary edema.

Rationale: The septic client who suddenly develops dyspnea, crackles, hypertension, bounding pulses, agitation, and confusion most likely has developed noncardiogenic pulmonary edema. Agitation and confusion are often among the first signs of developing hypoxemia, which would be common to both cardiogenic and noncardiogenic pulmonary edema. Hypertension and bounding pulses are more common with noncardiogenic pulmonary edema. Right-sided heart failure, left-sided heart failure, and constrictive pericarditis are considered cardiogenic causes for pulmonary edema.



9. A student is accompanying the nurse today. A newly admitted ICU client with a diagnosis of pulmonary edema has an elevated JVD and an S3. Based upon these assessment findings, the nurse indicates to the student that this is which type of pulmonary edema?

1. Cardiogenic 2. Neurogenic3. High altitude4. Excessive IV fluid administration

Correct Answer: Cardiogenic

Rationale: The nurse knows that cardiogenic pulmonary edema clients will have elevated JVD and an S3 extra heart sound. Cardiogenic-related pulmonary edema clients may also have hypotension with tachycardia instead of tachycardia with hypertension found with noncardiogenic causes. Neurogenic, high altitude, and excessive IV fluid administration are all types of noncardiogenic pulmonary edema.



10. An ICU client who was in a motor vehicle accident 1 day ago is developing a worsening respiratory status. The nurse is aware that the client’s chest has bruising on it from hitting the steering wheel, and the health care provider has diagnosed the client with lung contusions. As the client develops increased respiratory distress, the nurse recognizes that the only difference between acute lung injury (ALI) and acute respiratory distress syndrome (ARDS) is:

1. ARDS and ALI differ only in the amount of hypoxemia.2. ARDS clients will have a lower respiratory rate than ALI clients.3. ALI clients have fewer injuries than ARDS clients.4. ALI clients have more inflammation than ARDS clients.

Correct Answer: ARDS and ALI differ only in the amount of hypoxemia.

Rationale: The difference between ALI and ARDS is based upon the amount of hypoxemia. ALI is less severe of a disease process. The other answer choices are not representative of the difference between ARDS and ALI.

Cognitive Level: ApplicationNursing Process: DiagnosisClient Need: Physiological IntegrityLO: 4


11. The client has just been diagnosed with acute respiratory distress syndrome (ARDS). The nurse is aware that both acute lung injury (ALI) and ARDS clients will often require:

Mechanical ventilation. Frequent suctioning. Frequent ice chips. A living will.

Correct Answer: Mechanical ventilation.

Rationale: ALI and ARDS clients will likely require mechanical ventilation to support their respiratory status. While they may also require frequent suctioning, this is more client specific. Frequent ice chips and a living will are not necessary for ALI and ARDS clients.



12. An ICU client’s chest x-ray results indicate bilateral patchy infiltrates. The client is hypoxic. The client is being prepared for intubation. The ABGs indicate alkolosis. What other assessment findings might the nurse anticipate if the client’s condition continues to worsen?

1. Hypotension2. Hypertension3. Decreasing HCO3

4. Hyperventilation

Correct Answer: Hypotension

Rationale: The worsening client will eventually develop hypotension and acidosis. Thus, as the client continues to fail, the client will not develop hypertension. The HCO3 may increase to attempt to compensate for the developing acidosis. Hyperventilation is an early sign of ARDS and will help create the initial alkolosis.



13. A mechanically ventilated client develops respiratory alkalosis while on the ventilator. The high-pressure alarm has sounded frequently for this client. The ICU nurse suspects which of the following?

1. The client is on assist control mode.2. The client is on SIMV mode and the set rate is too low.3. The client is on pressure support mode.4. The client is on pressure-controlled setting.

Correct Answer: The client is on assist control mode.

Rationale: A frequent problem with assist control mode is stacked breaths, and the client can develop respiratory alkalosis. SIMV mode with a set rate too high may also cause respiratory alkalosis, but this is uncommon. This client is most likely not on pressure support mode or pressure-controlled setting.

Cognitive Level: ApplicationNursing Process: PlanningClient Need: Safe, Effective Care EnvironmentLO: 5


14. The ventilated ICU client develops hypotension after the respiratory therapist implements the most recent health care provider orders. The nurse suspects which ventilator mode might be the cause?

1. PEEP2. SIMV mode 3. Assist control mode4. Pressure-controlled setting

Correct Answer: PEEP

Rationale: Increasing PEEP levels can cause declining blood pressure. Hypotension is not commonly caused by the adjustment of other modes on the ventilator.

Cognitive Level: ApplicationNursing Process: AssessmentClient Need: Safe, Effective Care EnvironmentLO: 5


15. A client is on SIMV with a rate of 24. The nurse may question this order since:1. The rate could be too high for this mode.2. The client will be more comfortable with a different mode.3. The client is not receiving enough sedation.4. SIMV is always used in combination with PEEP.

Correct Answer: The rate could be too high for this mode.

Rationale: SIMV is usually set so that the client can breathe over the set rate to exercise the respiratory muscles. A rate of 24 will not allow this and could also establish autoPEEP. The client will not necessarily be more comfortable with a different mode—SIMV is the most commonly used mode in an ICU setting. Too much sedation is contraindicated in SIMV, so that the client will initiate breaths on his or her own. PEEP can be used with any of the modes.



16. The mechanically ventilated client requires increasing PEEP for worsening ARDS. The order for PEEP is now at 20 cm of H2O. The nurse will need to contact the health care provider immediately if the client develops which of the following?

1. Lung sounds greater on one side than the other2. Lung sounds with crackles3. Diminished peripheral pulses4. High-pressure alarm

Correct Answer: Lung sounds greater on one side than the other

Rationale: A potential complication from increasing PEEP is a pneumothorax. The nurse needs to be alert to diminishing or absent lung sounds on one side of the chest. Crackles and diminished peripheral pulses would not be related to the pneumothorax. A low-pressure alarm would be more likely to sound if the client developed a pneumothorax.



17. The mechanically ventilated client who suddenly develops cardiac arrhythmias from increasingly higher PEEP most likely has an underlying issue from which of the following?

1. Decreased cardiac output and acidosis2. Increased cardiac output and alkalosis3. Decreased cardiac output and renal failure4. Increased cardiac output and electrolyte disturbance

Correct Answer: Decreased cardiac output and acidosis

Rationale: Increasingly higher PEEP with decreased cardiac output and acidosis may predispose the client to cardiac arrhythmias. The other answer choices are not the most likely underlying issues.



18. A client has ventilator settings as follows: SIMV 16, PEEP 20 cm of H2O, FiO2 45%, tidal volume .450 liters. What concerns will the nurse have for this client?

1. Barotrauma2. Volutrauma3. Sinusitis4. Oxygen toxicity

Correct Answer: Barotrauma

Rationale: This client will be at risk for barotraumas due to the high PEEP levels. The tidal volume is within a standard setting. However, if it were high, it could lead to volutrauma. Sinusitis is a potential complication of ventilated clients, but this client should not have any higher risk for this. The FiO2 is set at 45%, which is not high. A FiO2

greater than 50% for an extended period of time can lead to oxygen toxicity.



19. The ICU nurse consulted with the client’s health care provider and the decision was made to intubate the client. The nurse anticipates the health care provider will require which of the following items in order to successfully intubate the client?

1. Nonsterile gloves, stylet, endotracheal tube, lubricant, laryngoscope handle and blade, resuscitation bag with a swivel adapter, and syringe

2. Gloves, lubricant, laryngoscope handle and blade, resuscitation bag with a swivel adapter, and ventilator

3. Sterile gloves, endotracheal tube, lubricant, laryngoscope handle and blade, resuscitation bag with a swivel adapter, and syringe

4. Gloves, stylet, lubricant, laryngoscope handle and blade

Correct Answer: Nonsterile gloves, stylet, endotracheal tube, lubricant, laryngoscope handle and blade, resuscitation bag with a swivel adapter, and syringe

Rationale: The most inclusive list entails the nonsterile gloves, stylet, endotracheal tube, lubricant, laryngoscope handle and blade, resuscitation bag with a swivel adapter, and syringe. The other lists exclude important items. The client can be manually ventilated until a ventilator arrives. Sterile gloves are not required.

Cognitive Level: ApplicationNursing Process: PlanningClient Need: Safe, Effective Environment LO: 7


20. The ICU nurse is contacted by the x-ray department following a postintubation chest x-ray. The nurse is advised that the endotracheal tube is located in the right bronchus. The nurse recognizes that the correct intervention for this problem is:

1. The tube needs to be withdrawn slightly.2. The tube needs to be inserted further.3. The tube is correctly placed.4. The tube is incorrectly attached to the ventilator.

Correct Answer: The tube needs to be withdrawn slightly.

Rationale: The right bronchus is easy to intubate due to the anatomy of the lung. If the tube is located in the right bronchus, it will need to be withdrawn slightly so that both lungs can be ventilated.

Cognitive Level: ApplicationNursing Process: AssessmentClient Need: Safe, Effective Care EnvironmentLO: 7


21. An intubated client has the following assessment data: rhonchi, pulse oximeter – 92%, soft abdomen, heart rate 88, blood pressure 98/54. What is the nurse’s first priority?

1. Suction the client.2. Contact the health care provider.3. Increase the oxygen.4. Start dopamine.

Correct Answer: Suction the client.

Rationale: The presence of rhonchi suggests the client needs to be suctioned. The other assessment data are of no consequence; therefore there is no need to contact the health care provider or increase the oxygen. The relative hypotension can be caused by the client being ventilated and does not require dopamine for blood pressure support.



22. Which health care provider order should the nurse question?

1. Endotracheal suctioning every hour2. Endotracheal suctioning as needed3. Maintain NPO status while client is ventilated4. Intake and output every 4 hours

Correct Answer: Endotracheal suctioning every hour

Rationale: Suctioning of a client should always be based upon client need and not routinely ordered. The other orders would be not be abnormal.

Cognitive Level: ApplicationNursing Process: ImplementationClient Need: Safe, Effective Care EnvironmentLO: 8


23. The client is on PEEP of 10 cm of H2O. The nurse ensures that which of the following is utilized for this client?

1. Closed-system suctioning2. Oral care daily3. Open-system suctioning4. Vital signs every shift

Correct Answer: Closed-system suctioning

Rationale: Closed-system suctioning should be utilized for clients with high PEEP and those who potentially have an aerosolized infectious disease. Oral care should be frequent and is related to intubation, not particularly PEEP. With high levels of PEEP, frequent vital signs and assessments are required to detect any potential complications.

Cognitive Level: ApplicationNursing Process: ImplementationClient Need: Health Promotion and MaintenanceLO: 8


24. A ventilated client has become hypoxic, with a pulse oximeter reading falling from 98% to 88%. The high-pressure alarm is sounding on the ventilator. The nurse has checked the tubing integrity and found no problems. The nurse has assessed the lung sounds and the sounds are equal bilaterally, but adventitious sounds are present. What action will the nurse take next?

1. Suction the client.2. Contact the health care provider.3. Turn the client on his side.4. Silence the alarm.

Correct Answer: Suction the client.

Rationale: When the tubing integrity is intact and the high-pressure alarm is sounding, along with pulse oximeter readings falling from 98% to 88% and adventitious breath sounds present, this indicates the client needs to be suctioned. The health care provider will not need to be contacted unless the nursing actions are unsuccessful at resolving the hypoxia. Turning the client on his side has no purpose. Silencing the alarm will not resolve the issue.



25. The family of a mechanically ventilated client receiving a chest tube asks why the tube is necessary. The nurse responds:

1. “The chest tube helps to decompress the lung and prevents further complications.”2. “The chest tube helps the client breathe more easily when on a ventilator.”3. “The chest tube is an elective procedure that many health care providers like to

perform.”4. “The chest tube requires the client to go to surgery for placement.”

Correct Answer: “The chest tube helps to decompress the lung and prevents further complications.”

Rationale: The chest tube is indicated for a pneumothorax that can be spontaneous or brought on by increasingly higher PEEP. It will not be an elective procedure and is most often performed at the bedside. A chest tube does not directly assist a client with breathing easier on a ventilator, but it will allow the lung to expand more fully, which helps with the client’s overall oxygenation.



26. A client is receiving a tracheostomy. The nurse has which of the following ready in case of a potential complication?

1. Chest tube set-up2. Surgical team on standby3. Sedation4. Aerosol treatment

Correct Answer: Chest tube set-up

Rationale: One of the complications of the insertion of a tracheostomy is a pneumothorax. Therefore, a chest tube set-up should be available during and immediately after the procedure. A surgical team is not always necessary for placement of a tracheostomy, but can be performed in the operating room at the discretion of the surgeon. However, the insertion of a tracheostomy is not considered a complication, and therefore a surgical team on standby as a potential complication is not required. Sedation and aerosol treatments are required in case of a potential complication. These are routine treatments.

Cognitive Level: ApplicationNursing Process: PlanningClient Need: Safe and Effective EnvironmentLO: 9


27. It is the beginning of the shift and the nurse has just received reports on four clients. Which client is it most important for the nurse to visit first?

1. Client with a chest tube complaining of difficulty breathing2. Client with a tracheostomy who is on oxygen via trach mask3. Client preparing for discharge following a lengthy hospital stay for ARDS4. Client complaining of incisional pain

Correct Answer: Client with a chest tube complaining of difficulty breathing.

Rationale: The nurse first will want to check on the client with a chest tube who is complaining of difficulty breathing, as many potential complications will need to be evaluated. The client complaining of incisional pain will need to be assessed for pain medication following the first client. Then the client with a tracheostomy who is having no problems will need to be assessed, followed by the client preparing for discharge.

Cognitive Level: AnalysisNursing Process: ImplementationClient Need: Safe, Effective Care EnvironmentLO: 9


ch36.doc

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