chapter 70 Flashcards
To evaluate the effectiveness of prescribed therapies for a client with ventilatory failure,
which of the following diagnostic tests 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
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
client’s ventilatory failure.
The nurse is caring for a client who has been admitted with a pulmonary embolism and
notes a change in the client’s oxygen saturation (SpO2) from 94% to 88%. Which of the
following actions should the nurse implement?
a. Increase the oxygen flow rate.
b. Suction the client’s oropharynx.
c. Assist the client to cough and deep breathe.
d. Help the client to sit in a more upright position.
A
Increasing oxygen flow rate usually will improve oxygen saturation in clients 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.
The nurse is caring for a client with respiratory failure who has a respiratory rate of 8/min
and a SpO2 of 89%. The client is increasingly lethargic. Which of the following actions
should the nurse anticipate?
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
The client’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 client’s respiratory rate is so low. Insertion of a
mini-tracheostomy will facilitate removal of secretions, but it will not improve the client’s
respiratory rate or oxygenation. BiPAP requires that the client initiate an adequate
respiratory rate to allow adequate gas exchange.
The pulse oximetry for a client with right lower lobe pneumonia indicates an oxygen
saturation of 90%. The client has rhonchi, a weak cough effort, and complains of fatigue.
Which of the following actions is best for the nurse to take?
a. Position the client on the right side.
b. Place a humidifier in the client’s room.
c. Assist the client with staged coughing.
d. Schedule a 2-hour rest period for the client.
C
The client’s assessment indicates that assisted coughing is needed to help remove
secretions, which will improve oxygenation. A 2-hour rest period at this time may allow
the oxygen saturation to drop further. Humidification will not be helpful unless the
secretions can be mobilized. Positioning on the right side may cause a further decrease in
oxygen saturation because perfusion will be directed more toward the more poorly
ventilated lung.
The nurse is caring for an obese client with left lower lobe pneumonia. Which of the
following positions should the nurse place the client in for optimal gas exchange?
a. Left lateral
b. Right lateral
c. Tripod position.
d. High Fowler’s position
B
The client should be positioned with the “good” lung in the dependent position to improve
the match between ventilation and perfusion. The obese client’s abdomen will limit
respiratory excursion when sitting in the high Fowler’s or tripod positions.
The nurse is admitting a client who is in possible respiratory failure with a high PaCO2.
Which of the following assessment information will be of most concern to the nurse?
a. The client is somnolent.
b. The client’s SpO2 is 90%.
c. The client complains of weakness.
d. The client’s blood pressure is 162/94 mmHg.
A
Increasing somnolence will decrease the client’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.
Chest physiotherapy is indicated for which of the following clients?
a. Takes a bronchodilator
b. Produces 40 mL of sputum per 24 hours
c. Has an increased PCO2 level
d. Is taking vancomycin
B
Chest physiotherapy is indicated in clients who produce more than 30 mL of sputum per
day or have evidence of severe atelectasis or pulmonary infiltrates. Vancomycin therapy is
not an indication for chest physio unless there is sputum present >30 mL/day. A client on a
bronchodilator does not necessarily require chest physio. An increased PCO2 level is not
an indication for chest physio.
The nurse is caring for a client who develops increasing dyspnea and hypoxemia 2 days
after having cardiac surgery. To determine whether the client has acute respiratory
distress syndrome (ARDS) or pulmonary edema caused by left ventricular failure, the
nurse will anticipate assisting with which of the following actions?
a. Inserting a pulmonary artery catheter
b. Obtaining a ventilation–perfusion scan
c. Drawing blood for arterial blood gases
d. Positioning the client for a chest radiograph
A
Pulmonary artery wedge pressures are normal in the client 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 of the following assessment findings by the nurse when caring for a client 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 client has subcutaneous emphysema.
b. The client has a sinus bradycardia with a rate of 52.
c. The client’s PaO2 is 50 mm Hg and the SaO2 is 88%.
d. The client has bronchial breath sounds in both the lung fields.
A
The subcutaneous emphysema indicates barotrauma caused by positive pressure
ventilation and PEEP. Bradycardia, hypoxemia, and bronchial breath sounds are all
concerns and will need to be addressed, but they are not indications that PEEP should be
reduced.
Which of the following statements by the nurse when explaining the purpose of positive
end-expiratory pressure (PEEP) to the family members of a client 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
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 client.
When prone positioning is used in the care of a client with acute respiratory distress
syndrome (ARDS), which of the following information obtained by the nurse indicates
that the positioning is effective?
a. The client’s PaO2 is 90 mm Hg, and the SaO2 is 92%.
b. Endotracheal suctioning results in minimal mucous return.
c. Sputum and blood cultures show no growth after 24 hours.
d. The skin on the client’s back is intact and without redness.
A
The purpose of prone positioning is to improve the client’s oxygenation as indicated by the
PaO2 and SaO2. The other information will be collected but does not indicate whether
prone positioning has been effective.
The nurse obtains the vital signs for a client admitted 2 days ago with gram-negative
sepsis: temperature 38.4°C (101.1°F), blood pressure 90/56 mm Hg, pulse 92 beats/minute,
respirations 34/minute. Which of the following actions should the nurse take next?
a. Administer the scheduled IV antibiotic.
b. Give the PRN acetaminophen 650 mg.
c. Obtain oxygen saturation using pulse oximetry.
d. Notify the health care provider of the client’s vital signs.
C
The client’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 client. Administration of the
scheduled antibiotic and administration of acetaminophen also will be done, but they are
not the highest priority for a client who may be developing ARDS.
To decrease the risk for ventilator-associated pneumonia, which of the following actions
should the nurse include in the plan of care for a client 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 45 degrees.
d. Give enteral feedings at no more than 10 mL/hour.
C
Elevation of the head decreases the risk for aspiration. PEEP is frequently needed to
improve oxygenation in clients receiving mechanical ventilation. Suctioning should be
done only when the client assessment indicates that it is necessary. Enteral feedings should
provide adequate calories for the client’s high energy needs.
The nurse is caring for a client who has a nursing diagnosis of ineffective airway clearance
related to thick, secretions. Which of the following actions should the nurse include in the
plan of care?
a. Encourage use of the incentive spirometer.
b. Offer the client fluids at frequent intervals.
c. Teach the client the importance of coughing.
d. Increase oxygen level to keep O2 saturation >95%.
B
Since the reason for the poor airway clearance is the thick secretions, the best action will
be to encourage the client 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 client’s gas exchange, but they do not address
the thick secretions that are causing the poor airway clearance.
The nurse is caring for a client with acute respiratory distress syndrome (ARDS) who is
intubated, receiving mechanical ventilation and has developed a pneumothorax. Which of
the following actions will the nurse anticipate taking?
a. Lower the positive end-expiratory pressure (PEEP).
b. Increase the fraction of inspired oxygen (FIO2).
c. Suction more frequently.
d. Increase the tidal volume.
A
Because barotrauma is associated with high airway pressures, the level of PEEP should be
decreased. The other actions will not decrease the risk for pneumothorax.
