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Respiratory Emergencies
Which client will the nurse assess most frequently for a venous thromboembolism (VTE) to prevent harm from a pulmonary embolism (PE)? A. 75-year old with left heart failure B. 65-year-old with breast cancer C. 55-year-old after a total knee replacement D. 44-year-old with type 2 diabetes mellitus - correct answers C VTEs leading to PE most often form in a vein in the legs or the pelvis, especially after total joint replacement surgery. The surgery disrupts some venous blood flow and most clients are less mobile for days after the surgery, which also increases the risk. Which additional assessment findings support the nurse's suspicion that the client who reports a sudden onset of shortness of breath may have a pulmonary embolism (PE)? Select all that apply? A. Sp0, 85% B. Hoarseness C. Diaphoresis D. Hypertension E.Crushing chest pain radiating to the jaw F. Crackles in a lower lung lobe - correct answers A, C, F Common assessment findings for PE include sudden onset of stabbing chest pain, apprehen-sion, restlessness, feeling of impending doom, cough, hemoptysis, diaphoresis, increased respiratory rate, hypotension, crackles in the affected lung areas, pleural friction rub, tachycardia, S or Sa heart sound, low-grade fever, petechiae over chest and axillae, and decreased arterial oxygen saturation.
Respiratory Emergencies
In addition to arterial blood gas levels, for which diagnostic test will the nurse prepare a client who is suspected to have a pulmonary embolism (PE)? A. Computed tomography pulmonary angiography B. Carbon monoxide diffusion capacity C. Pneumoencephalogram D. 12-lead ECG - correct answers A Which action will the nurse instruct an assistive personnel (AP) to avoid performing on a client after abdominal surgery to prevent harm from a pulmonary embolism? A. Encouraging fluid intake B. Massaging the clients calves C. Ambulating the client in the hall D. Changing the clients position every 2 hours - correct answers B Massaging the calves could cause an existing venous thrombus in the lower legs (most common place of formation) to break up and form emboli that could travel to the lungs. Increasing fluid intake, ambulation, and changing positions frequently reduces the risk for clot formation. Which actions are most appropriate for the nurse to take immediately when a client has indications of a pulmonary embolism (PE)? Select all that apply. A. Apply oxygen.
Respiratory Emergencies
Which change in a client's laboratory values does the nurse interpret as being consistent with the presence of a pulmonary embolism (PE)? A. pH 7. B. Elevated D-dimer C. Low levels of factor V Leiden D. Decreased leukocyte count - correct answers B The D-dimer level rises with fibrinolysis, making it consistent with a PE. However, other diagnostic testing is still needed to determine whether a PE has occurred. Which symptoms indicate to the nurse that the management of a client with a pulmonary embolism (PE) is not effective? Select all that apply. A. Partial thromboplastin time (PTT) is 2.0 times normal B. ECG shows increasing dysthythmias C. Client has stopped sweating D. Neck veins are distended E. Sacral edema is present F. Pulse oximetry is 88% - correct answers B, D, E, F Indications of a worsening PE include increasing dyspnea, dysrhythmias, distended neck veins, pedal or sacral edema, increasing crackles or other abnormal lung sounds, and cyanosis of the lips, conjunctiva, oral mucosa, and nail beds.
Respiratory Emergencies
The distended neck veins and sacral edema are associated with increasing pulmonary pressures from an extending PE that cause right-sided heart failure and systemic edema. Dysrhythmias and low pulse oximetry are indicators of hypox-emia from decreased pulmonary gas exchange. The nurse anticipates a prescription for which drug when the client with a pulmonary embolism being managed with IV crystalloids remains hypotensive with a low cardiac output? A. Alteplase B. Warfarin C. Morphine D. Dobutamine - correct answers D Dobutamine is an inotropic agent that increases myocardial contractility and can help increase cardiac output and raise blood pressure Which client information indicates to the nurse that management of a pulmonary embolism (PE) is effective? Select all that apply. A. Pulse oximetry of 95% B. Arterial blood gas, pH of 7. C. Clients desire to go home D. Absence of pallor or cyanosis E. Mental status at client's baseline F. Palpable peripheral pulses - correct answers A, D, E, F
Respiratory Emergencies
D. Pao, 55 mm Ig E. pH value of < 7. F. Sao2 80% - correct answers B, D, E, F The critical ABG values that define or classify a respiratory problem as acute respiratory failure are a partial pressure of arterial oxygen (Pao,) of less than 60 mm Hg (hypoxemic oxygenation failure), or a partial pressure of arterial carbon dioxide (Paco,) of more than 45 mm Hg occurring with acidemia (pH < 7.35), and arterial oxygen saturation (Saoz) less than 90%. Which action is most important for the nurse to perform first for a client suspected of having acute respiratory failure? A. Initiating an IV B. Applying oxygen C. Calling the Rapid Response Team D. Asking the client about a history of respiratory disorders - correct answers B Oxygen therapy is appropriate for any client with acute hypoxemia caused by acute respiratory failure and is started first (while another person is calling the Rapid Response Team). Which client will the nurse consider to be at greatest risk for acute respiratory distress syndrome (ARDS)? A. 22-year-old who received 10 units of blood after a motor vehicle accident B. 24-year-old with asthma who has not taken prescribed asthma medications for 2 weeks
Respiratory Emergencies
C. 62-year-old with chronic obstructive pulmonary disease who has pneumonia D. 78-year-old with chronic heart failure and pulmonary edema - correct answers A Extensive trauma alone can cause an excessive release of intracellular enzymes that can damage lung cells and lead to ARDS. The 10 units of blood indicate severe trauma. In addition, with massive transfusions there is redistribution of large volumes of blood into the pulmonary circulation, which increases pulmonary capillary hydrostatic pressure contributing to movement of fluid into lung tissue causing noncardiac pulmonary edema. Plasma proteins from this edema start inflammatory processes in the lung tissues leading to ARDS. Which assessment will the nurse perform first when a client at risk for acute respiratory distress syndrome (ARDS) becomes cyanotic and diaphoretic? A. Compare current ECG tracing with baseline measurement. B. Measure the blood pressure in both arms. C. Auscultate breath sounds bilaterally. D. Measure pulse oximetry. - correct answers D In early ARDS, hypoxemia may be the only abnormal assessment finding and can be life threatening. Which phase of acute respiratory syndrome (ARDS) case management does the nurse identify for a client who has been intubated for 6 days and has progressive hypoxemia that responds poorly to high levels of oxygen? A. Resolution phase B. Recovery phase
Respiratory Emergencies
B. Oxygen saturation is greater than 50%. C. End-tidal carbon dioxide level is 38 mm Hg. D. No air is heard in the stomach when auscultated with a stethoscope. - correct answers C The end-tidal carbon dioxide level is within the normal range. If the endotracheal tube were in the esophagus or stomach rather than the trachea, it would be very low or undetectable. For which problems will the nurse specifically assess when the high-pressure alarm of a client's mechanical ventilator sounds? Select all that apply. A. Mucus plug B. Bronchospasm C. Client coughing D. Air leak in tube cuff E. Client fighting the ventilator F. Ventilator tubing disconnected - correct answers A, B, C, E Common causes of alarms indicating high pressure include: presence of increased airway secretions or mucous plugs, client coughing or gaging, client fighting or "bucking" the ventila-tor, anything that decreases airway size (i.e., bronchospasms), presence of a pneumothorax, displacement of the endotracheal tube further into the tracheobronchial tree, and external obstruction of the tubing An air leak in the tube cuff or disconnection of the ventilator tubing results in low pressure, not high pressure.
Respiratory Emergencies
Which clients will the nurse expect to most likely need to be intubated and mechanically ventilated? Select all that apply. A. 25-year-old with burns who has severe swelling of oral mucosa B. 38-year-old with copious secretions and ineffective cough C. 45-year-old with SpO, of 93% on a high-flow oxygen face mask D. 56-year-old with pneumonia, increasing fatigue, and shallow respirations E. 62-year-old with COPD who is able to cough and has an SpO2 of 90% F. 72-year-old with moderate heart failure and orthopnea - correct answers A, B, D Which action will the nurse take first to prevent harm for a client being mechanically ventilated who is biting and chewing at the endotracheal tube (ET)? A. Request an order for soft wrist restraints. B. Immediately suction the client's mouth. C. Administer a paralyzing agent. D. Insert an oral airway. - correct answers D The ET must be kept stable to ensure it remains properly placed. Biting or chewing on the tube can destabilize it. A simple way to prevent this is by inserting an oral air way. What are the characteristics of a mechanical ventilator that is pressure-cycled? Select all that apply. A. Its main function is to provide positive pressure only during expiration to keep lungs partially inflated.
Respiratory Emergencies
- Keeping the head of the bed elevated at least 30 degrees
- Performing oral care per agency policy (usu-ally brushing teeth at least every 12 hours and antimicrobial rinse)
- Oral pressure injury prophylaxis
- Preventing aspiration
- Pulmonary hygiene (i.e., chest physiotherapy, postural drainage, and turning and positioning Which assessment finding for a client who is receiving mechanical ventilation in synchronized intermittent mandatory ventilation (SIM) mode indicates to the nurse probable readiness to be weaned? A. Fever from a respiratory infection has resolved. B. Client is alert and oriented to place and person. C. Client receives 1-2 mechanical ventilator breaths/min. D. Arterial blood gas values are maintained within normal limits. - correct answers C Which assessment finding does the nurse expect for a client who was extubated 2 hours ago? A. Restlessness B. Hoarseness C. Dyspnea D. Stridor - correct answers B
Respiratory Emergencies
Which conditions indicate to the nurse that a client being mechanically ventilated needs to be suctioned? Select all that apply. A. Presence of ronchi when listening to breath sounds B. Presence of moisture in the ventilator tubing C. Audible secretions in the endotracheal tube D. Low-pressure alarm sounds E. Increased peak inspiratory pressure (PIP) F. Tubing becomes disconnected from the ventilator - correct answers A, C, E The most common indicator of the need for suctioning is the presence of coarse crackles (rhonchi) over the trachea. Other indicators or conditions requiring suctioning include excessive secretions, increased peak airway (inspira-tory) pressure (PIP), and decreased breath sounds. Which assessment is most important for the nurse to perform for a client with chest trauma who is at high risk for a pulmonary contusion? A. Observing for chest movements B. Aulscultating for breath sounds C. Listening for hyperresonance D. Observing for deviation - correct answers B Clients with a pulmonary contusion often first present with decreased breath sounds or crackles and wheezes over the affected area.
