Chapter 29: Critical Care If Patients With Respiratory Emergencies Flashcards
A client who is 3 days postoperative from extensive abdominal surgery for cancer reports having a difficult time “catching her breath” and having a reddish-purple, nonitchy rash on her chest. After assessing the client, what is the nurse’s best action or response to prevent harm?
A. Ask the client about possible drug allergies
B. Apply oxygen and call the rapid response team
C. Determine when she last received an opioid dose
D. Check the oxygen saturation and encourage her to cough
Answer: B
Rationale:
This client is at high risk for developing a pulmonary embolism from a venous thromboembolism (has cancer and recently underwent extensive abdominal surgery). She has two major symptoms of PE, sudden onset shortness of breath and petechiae on her chest. These are significant enough to call the rapid response team because and without assessing oxygen saturation or most recent opioid dose (she has no symptoms of respiratory depression) because time is of the essence in starting appropriate therapy to prevent permanent lung damage or death. Applying oxygen can help improve her gas exchange and should be done immediately. Rash caused by a drug allergy are usually red, raised, itchy, and do not look like petechiae.
Which condition, sign, or symptom does the nurse consider most relevant in assessing a client suspected to have ARDS? Select all that apply.
A. Dyspnea
B. Electrocardiograph shows ST elevation
C. Intercostal retractions
D. PaO2 84% on oxygen at 6 L/minute
E. Substernal pain or rubbing
F. Wheezing on exhalation
Answers: A, C, D
Rationale:
The defining feature of ARDS is continued hypoxemia despite vigorous oxygen therapy. The hypoxia and hypoxemia triggers dyspnea and an increased breathing effort seen as intercostal retractions. Substernal pain or rubbing are not associated with ARDS. The pathophysiological problems of ARDS are in the lung tissue and not in the airways. Thus, wheezing is not a manifestation of the disorder. Although the hypoxia stimulates a variety of dysrhythmias, there are no specific ECG changes. ST elevation is associated with an evolving myocardial infarction.
The client is a 5 foot 11 inch tall, 176 lb (80 kg) woman who has been mechanically ventilated at a tidal volume of 400 mL and a respiratory rate of 12 breaths per minute for the past 24 hours. The most recent arterial blood gas (ABG) results for this client are:
pH= 7.32; PaO2 = 84 mm Hg; PaCO2 = 56 mm Hg. What is the nurse’s interpretation of these results?
A. Ventilation adequate to maintain oxygenation.
B. Ventilation excessive; respiratory alkalosis present.
C. Ventilation inadequate; respiratory acidosis present.
D. Ventilation status cannot be determined from information presented.
Answer: C
Rationale:
The average-size adult female has a normal tidal volume of 400-500 mL. However this client is larger than average and would have a greater tidal volume. Usually the tidal volume is set at 6 to 8 mL/kg of body weight, which would range between 480mL to 640 mL. At the current tidal volume setting this woman is being underventilated with inadequate gas exchange. Not enough oxygen is available and not enough carbon dioxide is being lost leading to respiratory acidosis.
Which symptom or change in assessment of a client with 4 broken ribs on the right side indicates to the nurse the possibility of a tension pneumothorax?
A. Distended neck veins
B. Mediastinal shift toward the left side
C. Right-sided pain on deep inhalation
D. Right side of the chest more prominent than the left
Answer: A
Rationale:
Any type of pneumothorax can shift the mediastinum to the unaffected side and cause the affected side to be more prominent. Pain on deep inhalation is related to the broken ribs and not a pneumothorax. The distended neck veins are a strong indicator of the life-threatening tension pneumothorax and immediate action is needed.
A client who is 3 days postoperative from extensive abdominal surgery for cancer reports having a difficult time “catching her breath” and having a reddish-purple, nonitchy, rash on her chest. After assessing the client, what is the nurse’s best action or response to prevent harm?
A. Ask the client about possible drug allergies
B. Apply oxygen and call the rapid response team
C. Determine when she last received an opioid dose
D. Check the oxygen saturation and encourage her to cough
Answer: B
Rationale:
This client is at high risk for developing a pulmonary embolism from a venous thromboembolism (has cancer and recently underwent extensive abdominal surgery). She has two major symptoms of PE, sudden onset shortness of breath and petechiae on her chest. These are significant enough to call the rapid response team because and without assessing oxygen saturation or most recent opioid dose (she has no symptoms of respiratory depression) because time is of the essence in starting appropriate therapy to prevent permanent lung damage or death. Applying oxygen can help improve her gas exchange and should be done immediately. Rash caused by a drug allergy are usually red, raised, itchy, and do not look like petechiae.
Which condition, sign, or symptom does the nurse consider most relevant in assessing a client suspected to have ARDS? Select all that apply.
A. Dyspnea
B. Electrocardiograph shows ST elevation
C. Intercostal retractions
D. PaO2 84% on oxygen at 6 L/minute
E. Substernal pain or rubbing
F. Wheezing on exhalation
Answers: A, C, D
Rationale:
The defining feature of ARDS is continued hypoxemia despite vigorous oxygen therapy. The hypoxia and hypoxemia triggers dyspnea and an increased breathing effort seen as intercostal retractions. Substernal pain or rubbing are not associated with ARDS. The pathophysiological problems of ARDS are in the lung tissue and not in the airways. Thus wheezing is not a manifestation of the disorder. Although the hypoxia stimulates a variety of dysrhythmias, there are no specific ECG changes. ST elevation is associated with an evolving myocardial infarction.
The client is a 5 foot 11 inch tall, 176 lb (80 kg) woman who has been mechanically ventilated at a tidal volume of 400 mL and a respiratory rate of 12 breaths per minute for the past 24 hours. The most recent arterial blood gas (ABG) results for this client are:
pH= 7.32; PaO2 = 84 mm Hg; PaCO2 = 56 mm Hg. What is the nurse’s interpretation of these results?
A. Ventilation adequate to maintain oxygenation.
B. Ventilation excessive; respiratory alkalosis present.
C. Ventilation inadequate; respiratory acidosis present.
D. Ventilation status cannot be determined from information presented.
Answer: C
Rationale:
The average-size adult female has a normal tidal volume of 400-500 mL. However, this client is larger than average and would have a greater tidal volume. Usually the tidal volume is set at 6 to 8 mL/kg of body weight, which would range between 480mL to 640 mL. At the current tidal volume setting this woman is being underventilated with inadequate gas exchange. Not enough oxygen is available and not enough carbon dioxide is being lost leading to respiratory acidosis.
Which symptom or change in assessment of a client with four broken ribs on the right side indicates to the nurse the possibility of a tension pneumothorax?
A. Distended neck veins
B. Mediastinal shift toward the left side
C. Right-sided pain on deep inhalation
D. Right side of the chest more prominent than the left
Answer: A
Rationale:
Any type of pneumothorax can shift the mediastinum to the unaffected side and cause the affected side to be more prominent. Pain on deep inhalation is related to the broken ribs and not a pneumothorax. The distended neck veins are a strong indicator of the life-threatening tension pneumothorax and immediate action is needed.
An attempt by a primary health care provider to intubate a client for mechanical ventilation is unsuccessful after 45 seconds. What is the nurse’s priority action?
A. Placing a naso-tracheal tube
B. Assessing for bilateral breath sounds
C. Assessing oxygen saturation by pulse oxymetry
D. Applying oxygen with a bag-valve-mask device
Answer: D
Rationale:
During the intubation procedure the client is not breathing. The intubation attempt should last not longer than 15 to 30 seconds. After 45 seconds the client is very hypoxic and assessing oxygen saturation is not necessary. The client needs oxygen as quickly as possible. Assessment for bilateral breath sounds is performed after intubation to determine ensure that the tube is not in one bronchus. Placing a naso-tracheal tube is not a bedside nursing function.
Which actions does the nurse ensure are performed for a client being mechanically ventilated to prevent ventilator-associated pneumonia (VAP)? Select all that apply.
A. Assessing temperature every 4 hours
B. Checking ventilator settings every 4 hours
C. Getting the patient out of bed as soon as prescribed
D. Keeping the head of the bed elevated to 30 degrees or above
E. Maintaining the client in the prone position
F. Providing adequate humidification
G. Providing meticulous mouth care every 12 hours
H. Suggesting that the pneumonia vaccine be prescribed
Answers: C, D, G
Rationale:
Getting the client out of bed as quickly as possible helps prevent VAP by reducing the risk for fluid stasis in the lungs and for aspiration, a common cause of VAP. Keeping the head of the bed elevated when the client is in bed also reduces the risk for aspiration. Meticulous oral care prevents colonization of bacteria that can move into the respiratory tract. Assessing temperature can help identify VAP early but does not prevent its occurrence. Checking the ventilator settings is crucial to ensure adequate gas exchange and prevent injury but does not prevent pneumonia. The prone position during mechanical ventilation is recommended only for clients with ARDS and does not prevent VAP. Humidifying the oxygen and air received by the client helps prevent drying of the respiratory tract but not VAP. VAP is not caused by the same organisms that cause infectious pneumonia and vaccination against these organisms does not prevent VAP.
A client being mechanically ventilated has all of the following changes. Which changes are most relevant in helping the nurse determine whether suctioning is needed at this time? Select all that apply.
A. Decreased SpO2
B. Elevated temperature
C. Crackles auscultated over the trachea
D. Crackles auscultated in the lung periphery
E. High pressure ventilator alarm sounds
F. Presence of fluid within the endotracheal tube
G. Presence of fluid within the ventilator tubing
Answers: A, C, E, F
Rationale:
Decreased SpO2 is often caused by excessive airway secretions and is a major indicator of the nees for suctioning. Crackles over the trachea are caused by fluid in the trachea and suctioning is needed to remove this fluid. Pressure is increased when resistance is present in the airway such as that caused by secretions. Fluid in the endotracheal tube indicates a need for immediate suctioning regardless of how recently it was last performed. Elevated temperature is not related to the need for suction. Crackles in the lung periphery would not be reduced by endotracheal suctioning. Fluid in the ventilator tubing is caused by condensation, not increased secretions in the airway.
Which client will the nurse consider to be at the greatest risk for developing acute respiratory distress syndrome (ARDS)?
A. A 22 year old with a fractured clavicle
B. A 39 year old with uncontrolled diabetes
C. A 56 year old with chronic kidney disease
D. A 74 year old who aspirates a tube feeding
CORRECT: D
A 74 year old who aspirates a tube feeding
ARDS is a type of acute respiratory failure with hypoxemia that persists even when 100% oxygen is given, decreased pulmonary compliance, dyspnea, bilateral pulmonary edema, and dense pulmonary infiltrates on x-ray (ground-glass appearance). It often occurs after an acute lung injury such as could result from aspiration of acidic gastric contents. Clients who are receiving tube feedings are at particular risk for lung damage by aspiration.
What is the primary emphasis for the nurse who is providing care to a client with acute respiratory distress syndrome (ARDS) currently in the exudative management stage of the disorder?
A. Assessing the client at least hourly for tachypnea and dyspnea
B. Performing meticulous mouth during mechanical ventilation
C. Assessing for abnormal lung sounds
D. Monitoring urine output to identify multiple organ dysfunction syndrome early
CORRECT: A
Assessing the client at least hourly for tachypnea and dyspnea
The exudative phase includes early changes of dyspnea and tachypnea resulting from the alveoli becoming fluid filled and from pulmonary shunting and atelectasis. Early interventions focus on frequent assessment of respiratory status, supporting the client, and providing oxygen.
What is the best first action when the nurse assesses that the respirations of a sedated client with a new tracheostomy have become noisy, and the ventilator alarms indicate high peak pressures but the ventilator tubing is clear?
A. Suctioning the tracheostomy tube
B. Remove the inner cannula of the tracheostomy
C. Humidifying the oxygen source
D. Increasing the percentage of oxygen
CORRECT: A
Suctioning the tracheostomy tube
The best first action by the nurse is to suction the tracheostomy tube. This will likely result in clear lung sounds and lower peak pressure. Humidifying the oxygen source may help mobilize secretions but is not an immediate helpful action. Increasing oxygenation does nothing to clear the airway of whatever is making it noisy and is elevating peak pressures. Removing the inner cannula of a ventilated client is contraindicated.
Which action will the nurse take first for a client being mechanically ventilated who begins to pick at the bedcovers?
A. Administering the prescribed sedating drug
B. Explaining to the client that the tube helps with breathing
C. Requesting that the family leave to decrease the client’s agitation
D. Assessing for adequate oxygenation
CORRECT: D
Assessing for adequate oxygenation
The best first action by the nurse would be to assess for adequate oxygenation. Restlessness, agitation, anxiety, and tachycardia are early symptoms of hypoxemia. Increasing sedation is not indicated for this client and may mask symptoms such as hypoxemia or worsening respiratory failure. Although the nurse may explain to the client that he or she is intubated, it does not take priority over assessing for hypoxemia. The presence of family members may decrease, not increase, the client’s anxiety.
