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293 Cards in this Set
- Front
- Back
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A patient has SvO₂ of 52%, CO of 4.8L/min, SpO₂ of 95%, and unchanged hemoglobin level. The nurse should assess the patient for:
a)dysrhythmias b)pain on movement c)pulmonary edema d)signs of septic shock |
B
The normal mixed venous oxygen saturation of 60-80% becomes decreased with decreased arterial oxygenation, low CO₂, low hemoglobin, or increased oxygen consumption. With normal CO, arterial oxygenation, and hemoglobin, the factor that is responsible for decreased SvO₂ is increased oxygen consumption, which can result from increased metabolic rate, pain, movement, or fever. |
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The nurse observes a PAWP waveform on the monitor when the balloon of the patient’s pulmonary artery catheter is deflated. The nurse recognizes that:
a)the potential is at risk for embolism because occlusion of the catheter with a thrombus b)the patient is developing pulmonary edema that has increased the pulmonary artery pressure c)the patient is at risk for an air embolus because the injected air cannot be withdrawn into the syringe d)the catheter must be immediately repositioned to prevent infarction or pulmonary artery rupture |
D
When a pulmonary artery pressure tracing indicates a wedged waveform when the balloon is deflated, this indicates that the catheter has advanced and has become spontaneously wedged. If the catheter is not repositioned immediately, a pulmonary infarction or a rupture of a pulmonary artery may occur. If the catheter is becoming occluded, the pressure tracing becomes blunted, and pulmonary edema and increased pulmonary congestion increase the pulmonary artery waveform. Balloon leaks found when injected air does not flow back into the syringe do not alter waveforms. |
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The use of the intraaortic balloon pump would be indicated for the patient with:
a)an insufficient aortic valve b)a dissecting thoracic aortic aneurysm c)generalized peripheral vascular disease d)acute myocardial infarction with heart failure |
D
The counterpulsation of the IABP increases diastolic arterial pressure, forcing blood back into the coronary arteries and main branches of the aortic arch, increasing coronary artery perfusion pressure and blood flow to the myocardium. The balloon pump also causes a drop in aortic pressure just before systole, decreasing afterload and myocardial oxygen consumption. These effects make the IABP valuable in treating unstable angina, acute myocardial infarction with heart failure, cadiogenic shock, and a variety of surgical heart situations. Its use is contraindicated in incompetent aortic values, dissecting aortic aneurysms, and generalized peripheral vascular disease. |
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The rapid deflation of the IABP causes a decreased _____.
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Afterload
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During intraaortic counterpulsations, the balloon is _____ during diastole.
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Inflated
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A primary effect of the IABP is increased _____ pressure.
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Diastolic
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To prevent arterial trauma during the use of the IABP, the nurse should:
a)reposition the patient q2h b)check the site for bleeding q1h c)prevent hip flexion of the cannulated leg d)cover the insertion sire with an occlusive dressing |
C
Because the IABP is inserted into the femoral artery and advanced to the descending thoracic aorta, compromised distal extremity circulation is common and requires that the cannulated extremity be extended at all times. Repositioning the patient is limited to side-lying or supine positions with the HOB elevated no more than 30-45°. Assessment for bleeding is important because the IABP may cause platelet destruction, and occlusive dressings are used to prevent site infection. |
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A patient who is hemodynamically stable has an order to wean IABP. The nurse should:
a)decrease the augmentation pressure to zero b)stop the machine since hemodynamic parameters are satisfactory c)stop the infusion flow through the catheter when weaning is initiated d)change the pumping ratio from 1:1 to 1:2 or 1:3 until the balloon is removed |
D
Weaning from the IABP involves reducing the pumping to every second or third heartbeat until the IABP catheter is removed. The pumping and infusion flow are continued to reduce the risk for thrombus formation around the catheter until it is removed. |
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A comatose patient with a possible cervical spine injury is intubated with a nasal endotracheal tube. The nurse recognizes that in comparison with an oral endotracheal tube, a nasal tube:
a)requires the placement of a bite block b)is more likely to cause laryngeal trauma c)requires greater respiratory effort in breathing d)provides for easier suctioning and secretion removal |
C
A nasal ET tube is longer and smaller in diameter than an oral ET tube, creating more airway resistance and increasing the work of breathing. Suctioning and secretion removal are also more difficult with nasal ET tubes, and they are more subject to kinking than are oral tubes. Oral tubes require a bite block to stop the patient from biting the tube and may cause more laryngeal damage because of the larger size. |
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In preparing a patient in the ICU for oral endotracheal intubation, the nurse:
a)places the patient supine with the head extended and neck flexed b)tells the patient that the tongue must be extruded while the tube is inserted c)positions the patient supine with the head hanging over the bed to align the mouth and trachea d)informs the patient that while it will not be possible to talk during insertion of the tube, speech will be possible after it is correctly placed |
A
The patient is positioned with the mouth, pharynx, and trachea in direct alignment with the head extended in the ‘sniffing position’, but the head must not be hung over the edge of the bed. The patient may be asked to extrude the tongue during nasal intubation. Speaking is not possible during intubation or while the tube is in place because the tube splits the vocal cords. |
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A patient has an oral ET tube inserted to relieve an upper airway obstruction and to facilitate secretion removal. The first responsibility of the nurse immediately following placement of the tube is to:
a)suction the tube to remove secretions b)secure the tube to the face with adhesive tape c)place an end tidal CO₂ detector on the ET tube d)assess for bilateral breath sounds and symmetric chest movement |
C
The first action of the nurse is to use end-tidal CO₂ detector. If no CO₂ is detected, the tube is in the esophagus. The second action by the nurse following ET intubation is to auscultate the chest to confirm bilateral breath sounds and observe to confirm bilateral chest expansion. If this evidence is present, the tube is secured and connected to an O₂ source. Then the placement is confirmed immediately with x-ray, and the tube is marked where it exits the mouth. Then the patient should be suctioned as needed. |
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The nurse uses the minimal occluding volume to inflate the cuff on an ET tube to minimize the incidence of:
a)infection b)hypoxemia c)tracheal necrosis d)accidental extubation |
C
The minimal occluding volume (MOV) involves adding air to the ET tube cuff until no leak is heard at peak inspiratory pressure but ensures that minimal pressure is applied to the tracheal wall to prevent pressure necrosis of the trachea. The minimal occluding volume should apply between 20-25mmHg of pressure on the trachea to prevent injury. The cuff does not secure the tube in place but rather prevents escape of ventilating gases through the upper airway. |
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After inflating an ET tube cuff, the nurse monitors the cuff pressure every _____ hours with a manometer to verify that the cuff pressure is _____ mmHg.
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8,
20-25 |
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Equipment that should be bedside for all patients undergoing endotracheal intubation includes _____ equipment and a _____.
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Suctioning
Bag-vale-mask |
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A catheter used to suction an ET tube should be no longer than _____ the diameter of the ET tube.
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Half
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When suctioning an ET tube, the nurse uses a suction pressure of _____ mmHg.
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100-120
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During ET tube suctioning, each suction pass should be no longer than _____ seconds.
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10
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To prevent hypoxemia during ET tube suctioning, the nurse always _____ the patient before and after suctioning.
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Hyperoxygenates
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The nurse suctions the patient’s ET tube when the patient:
a)has peripheral crackles in all lobes b)has not been suctioned for 2hours c)has coarse rhonchi over central airways d)needs stimulation to cough and deep-breathe |
C
Suctioning an ET tube is performed when adventitious sounds over the trachea or bronchi confirm the presence of secretions that can be removed by suctioning. Visible secretions in the ET tube, respiratory distress, suspected aspiration, increase in peak airway pressures, and changes in oxygen status are other indications. Peripheral crackles are not an indication of suctioning, and suctioning as a means of inducing a cough is not recommended because of complications associated with suctioning. |
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While suctioning the ET tube of a spontaneously breathing patient, the nurse notes that the patient develops bradycardia with premature ventricular contractions. The nurse should:
a)stop the suctioning and assess the patient for spontaneous respirations b)attempt to resuction the patient with reduced suction pressure and pass time c)stop the suctioning and ventilate the patient with slow, small-volume breaths using a bag-valve-mask (BVM) device d)stop suctioning and ventilate the patient with a BVM device with 100% oxygen until the HR returns to baseline |
D
If serious dysrhythmias occur during suctioning, the suctioning should be stopped, and the patient should be slowly ventilated with a BVM with 100% oxygen until the dysrhythmia subsides. Patients with bradycardia should not be suctioned excessively. Ventilation of the patient with slow, small-volume breaths using BVM is performed when severe coughing results from suctioning. |
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Two precautions taken during mouth care and repositioning of an ET tube to prevent and detect tube dislodgement:
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1-Use two nurses; one to hold the tube while it is untapped or the holder is loosened, and another to perform care
2-After completion of care, confirm the presence of bilateral breath sounds to ensure that the position of the tube was not changed and reconfirm cuff pressure |
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A patient with an oral ET tube has a nursing diagnosis of risk for aspiration related to presence of artificial airway. Appropriate nursing interventions for this patient are to (all that apply):
a)assess gag reflex b)ensure the cuff is properly inflated c)suction the patient’s mouth frequently d)raise the HOB 30-45° unless the patient is unstable e)keep the ventilator tubing cleared of condensed water |
B, C, D
Because the patient with an Et tube cannot protect the airway from aspiration and cannot swallow, the cuff should always be inflated and the HOB elevated while the patient is receiving tube feedings or mouth care is being performed. The HOB elevated 30-45° helps reduce risk. The mouth and oropharynx should be suctioned with Yankauer or tonsil suction to remove accumulated secretions that cannot be swallowed. Clearing the ventilator tubing of condensed water is important to prevent respiratory infection. |
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Although his oxygen saturation is above 92%, an orally intubated, mechanically ventilated patient is restless and very anxious. What interventions should be used first to decrease the risk of accidental extubation:
a)obtain an order and apply soft wrist restraints b)remind the patient that he needs the tube inserted to breathe c)administer sedatives and have a caregiver stay with the patient d)move the patient to an area close to the nurse’s station for closer observation |
C
Sedation may be appropriate as well as having someone the patient knows at the bedside talking to him. The other methods may need to be used. Restraints will need ongoing and frequent assessment of need. Reminding the patient may help, but it may not be enough to prevent the patient from pulling the tube if the patient becomes extremely anxious. |
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Four indications for mechanical ventilation:
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1.Apnea or impending inability to breathe
2.Acute respiratory failure 3.Severe hypoxemia 4.Respiratory muscle fatigue |
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Reduce intrathoracic pressure causing air to be pulled into lungs
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Negative-pressure vent
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Require an artificial airway
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Positive-pressure vent
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Expiration is passive
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Negative and positive pressure vent
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Most similar to physiologic ventilation
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Negative-pressure vent
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Applied to outside of the body
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Negative-pressure vent
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Most frequently used with acutely ill patients
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Positive-pressure vent
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Frequently used in the home for neuromuscular or nervous system disorders
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Negative-pressure vent
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Peak inspiratory pressure predetermined
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Pressure ventilator
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Preset volume of gas delivered with variable pressure based on compliance
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Volume ventilator
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Risk for hyperventilation and hypoventilation
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Pressure ventilator
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Volume delivered varies based on selected pressure and patient lung compliance
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Pressure ventilator
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Consistent volume delivered with each breath
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Volume ventilator
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Positive pressure applied throughout the entire respiratory cycle of spontaneously breathing patient _____
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CPAP (continuous positive airway pressure)
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Patient self-regulates the rate and depth of spontaneous respirations, but may also receive preset volume and frequency breaths by ventilator _____
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SIMV (synchronized intermittent mandatory ventilation)
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Positive pressure applied only during inspiration that supplies a rapid flow of gas _____
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PSV (pressure support ventilation)
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Preset tidal volume delivered at set frequency and more frequently when the patient attempts to inhale _____
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ACV (assist-control ventilation)
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Positive pressure applied to airway during exhalation _____
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PEEP (positive end-expiratory pressure)
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Delivery of small tidal volumes at a rapid respiratory rate _____
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HFV (high-frequency ventilation)
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Prolonged inspiration and shortened expiration set to promote alveolar expansion and prevent collapse _____
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PC/IRV (pressure controlled/inverse-ratio ventilation)
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A patient with acute respiratory failure is receiving assist-control mechanical ventilation with a peak end-expiratory pressure (PEEP) of 10cm H₂O. A sign that alerts the nurse to undesirable effects of increased airway and thoracic pressure is:
a)decreased BP b)decreased PaO₂ c)increased crackles d)decreased spontaneous respirations |
A
Positive-pressure ventilation, especially with end-expiratory pressure, increases intrathoracic pressure with compression of thoracic vessels, resulting in decreased venous return to the heart, decreased left ventricular end-diastolic volume (preload), decreased CO₂, and lowered BP. None of the other factors is related to increased intrathoracic pressure. |
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The nurse recognizes that a factor commonly responsible for sodium and fluid retention in the patient on mechanical ventilation is:
a)increased ADH release b)increased release of atrial natriuretic factor c)increased insensible water loss via the airway d)decreased renal perfusion with release of rennin |
D
Decreased CO associated with positive-pressure ventilation and positive end-expiratory pressure (PEEP) results in decreased renal perfusion, release of rennin, and increased aldosterone secretion, which causes sodium and water retention. ADH may be released because of stress, but ADH is responsible only for water retention, and increased intrathoracic pressure decreases, not increases, the release of atrial natriuretic factor, causing sodium retention. There is decreased, not increase, insensible water loss via the airway during mechanical ventilation. |
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A patient receiving mechanical ventilation is very anxious and agitated, and neuromuscular blocking agents are used to promote ventilation. The nurse recognizes that:
a)the patient will be too sedated to be aware of the details of care b)caregivers should be encouraged to provide stimulation and diversion c)the patient should always be addressed and explanations of care given d)communication will not be possible with the use of neuromuscular blocking agents |
C
Neuromuscular blocking agents produce a paralysis that facilitates ventilation, but they do not sedate the patient. It is important for the nurse to remember that the patient can hear, see, think, and feel and should be addressed and given explanations accordingly. Communication with the patient is possible, especially from the nurse, but visitors for an anxious and agitated patient should provide a calming, restful effect on the patient. |
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Five problems associated with inadequate nutrition in the patient receiving prolonged ventilation:
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1-Anemia resulting in poor O₂ transport
2-Decreased respiratory strength 3-Delayed weaning 4-Decreased resistance to infection 5-Prolonged recovery |
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The nurse determines that alveolar hypoventilation is occurring in a patient on a ventilator when:
a)the patient develops cardiac dysrhythmias b)auscultation reveals an air leak around the ET cuff c)ABG results show a PaCO₂ of 32mmHg and a pH of 7.47 d)the patient tries to breathe faster than the ventilator setting |
B
A leaking cuff can lower tidal volume or respiratory rates. An SIMV rate that is too low, the presence of lung secretions, or obstruction can decrease tidal volume. A decreased PaCO₂ and increased pH indicate a respiratory alkalosis from hyperventilation, and cardiac dysrhythmias can occur with either hyperventilation or hypoventilation. |
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When weaning a patient from a ventilator, the nurse plans:
a)to decrease the delivered FIO₂ concentration b)intermittent trials of spontaneous ventilation followed by ventilator support to provide rest c)substitution of ventilator support with a manual resuscitation bag if the patient becomes hypoxemic d)to implement weaning procedures around the clock until the patient does not experience ventilator fatigue |
B
A variety of ventilator weaning methods is used, but all should provide weaning trials with adequate rest between weaning trials to prevent respiratory muscle fatigue. Weaning is usually carried out during the day, with the patient ventilated at night until there is sufficient spontaneous ventilation without excess fatigue. In all methods, patients usually require a 10% increase in fraction of inspired oxygen (FiO₂) to maintain arterial oxygen tension. If the patient becomes hypoxemic, ventilator support is indicated. |
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A patient is to be discharged home with mechanical ventilation. Before discharge, it is most important for the nurse to:
a)teach the caregiver to care for the patient with a home ventilator b)help the caregiver plan for placement of the patient in a long-term facility c)stress the advantages for the patient in being cared for in the home environment d)have the caregiver arrange for around-the-clock home health nurses for the first several weeks |
A
Care of a ventilator-dependent patient in the home requires that the caregiver know how to manage the ventilator and take care of the patient on it. Te nurse should ensure that caregivers understand the potential sacrifices they may have to make and the impact that home mechanical ventilation will have over time, before final decisions and arrangements are made. Placement in long-term care facilities is not usually necessary unless the caregiver can no longer manage the care or the patient’s condition deteriorates. |
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The increase in emerging and untreatable infections is attributed to (select all):
a)the evolution of new infectious agents b)use of antibiotics to treat viral infections c)human population encroachment into wilderness areas d)transmission of infectious agents from humans to animals e)an increased number of immunosuppressed and chronically ill people |
A,B,C,E
Infectious agents, such as the HIV and the Hantavirus, have evolved to affect humans by closer association with animals as human populations push into wild animal habitats. (ie west nile). Bacterial agents have also become untreatable as the result of genetic and biochemical changes stimulated by unnecessary or inadequate exposure to antiobiotics. |
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The three antibiotic-resistant bacteria that are most current concern are:
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1-MRSA (methicillin-resistant Staphylococcus aureus)
2-VRE (vancomycin-resistant enterococci) 3-PRSP (penicillin-resistant Streptococcus pneumonia) |
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The priority teaching that the nurse should provide to a patient to prevent the development of antibiotic-resistant bacterial infections is to:
a)wash the hands after toileting and before eating b)avoid crowds and contact with others with infections c)take prescribed antibiotics at the frequency and for the duration directed d)request antibiotic therapy when a cold or the flu does not resolve in 2-3 days |
C
One of the most important factors in the development of antibiotic-resistant strains of organisms has been inappropriate use of antibiotics, and patients and their families should be taught to take full courses of prescribed antibiotics without skipping doses, not to request antibiotics for viral infections, not to take antibiotics prophylactically unless specifically prescribed, and not to take leftover antibiotics. Hand washing and avoiding others with infections are general measures to prevent transmission of infections. |
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The two recommended measures to prevent the transmission of hospital-acquired infections (HAIs) are:
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1-hand washing or alcohol-based sanitizers
2-use of PPEs (gloves,etc) |
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Which statements are transmissions for HIV the highest:
a)transmission to women or to men during sexual intercourse b)hollow-bore needle used for vascular access or used for IM injections c)vaginal or anal intercourse d)transfusion of whole blood or clotting factors e)first 2-6 months of infection or 1yr after infection f)perinatal transmission from HIV-infected mothers taking antiretroviral therapy or HIV-infected mothers using no therapy g)a splash exposure of HIV-infected blood on skin with an open lesion or a needle-stick exposure to HIV-infected blood |
a=women
b=vascular access c=anal intercourse d=whole blood e=first 2-6months of infection f=HIV-infected mothers using no therapy g=needle-stick exposure to HIV-infected blood |
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A primary reason that the normal immune response fails to contain HIV infection is that:
a)CD4⁺T cells drawn to the viruses become infected and are destroyed b)the virus inactivates B lymphocytes, preventing the production of HIV antibodies c)natural killer cells are destroyed by the virus before the immune system can be activated d)monocytes ingest infected cells, differentiate into macrophages, and shed viruses in body tissues |
A
Activated CD4⁺T cells are an ideal target for HIV because these cells are attracted to the site of concentrated HIV in the lymph nodes, where they become infected through viral contact with CD4 receptors. CD4⁺T cells normally are a major component of the immune system ineffective against HIV and other agents. The virus does not affect natural killer cells, and B lymphocytes are functional early in the disease, as evidenced by positive antibody titers against HIV. Monocytes do ingests infected cells and may become sites of HIV replication and spread the virus to other tissue, but this does not make the immune response ineffective. |
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CD4⁺T cells 200-500/µL
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Intermediate chronic infection
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Flulike symptoms
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Acute HIV infection
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Median length is about 11 years
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Early chronic infection
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HIV seroconversion
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Acute HIV infection
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Median length is 2 years
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Intermediate chronic infection
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CD4⁺T –cell count usually normal
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Early chronic infection
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Temporary fall of CD4⁺ cells
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Acute HIV infection
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Persistent fevers and night sweats
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Intermediate chronic infection
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Cytomegalovirus retinitis
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AIDS or late chronic infection
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Oral hairy leukoplakia
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Intermediate chronic infection
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Opportunistic diseases develop in AIDS because those disorders are:
a)side effects of drug treatment of AIDS b)sexually transmitted to individuals during exposure to HIV c)characteristic in individuals with stimulated B and T lymphocytes d)infections or tumours that are rarely occur with a competent immune system |
D
Organisms that are nonvirulent or that cause limited or localized diseases in an immunocompetent person can cause severe, debilitating, and life-threatening infections in persons with impaired immune function |
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A patient comes to the clinic and requests testing for HIV infection. Before administering testing, it is most important that the nurse:
a)ask the patient to identify all sexual partners b) determine when the patient thinks exposure to HIV occurred c)explain that all test results must be repeated at least twice to be valid d)discuss prevention practices to prevent transmission of the HIV to others |
B
Because there is median delay of 2 months after infection before antibodies can be detected, testing during this ‘window’ may result in false-negative results. Risky behaviours that may expose a person to HIV should be discussed and possible scheduling for repeated testing done. Positive results on initial testing will be verified by additional testing. Identification of sexual partners and prevention practices are important but do not relate immediately to the testing situation. |
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The ‘rapid’ HIV antibody testing is performed on a patient at high risk for HIV infection. The nurse explains that:
a)the test measures the activity of the HIV and reports viral loads as real numbers b)this test is highly reliable, and in 20 minutes the patient will know if HIV infection is present c)if the results are positive, another blood teat and a return appointment for results will be necessary d)this test detects drug-resistant viral mutations that are present in viral genes to evaluate resistance to antiretroviral drugs |
C
Although the ‘rapid’ test is highly reliable and results are available in about 20minutes, if results are positive from any testing, blood will be drawn for more specific enzyme-linked immunosorbent assay (ELISA) or western blot testing, and another visit will be necessary to obtain the results of the additional testing. CD4⁺ counts are not used for screening but rather are used to monitor the progression of HIV infection, and new assay tests measure resistance of the virus to antiviral drugs. |
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Treatment with two nucleoside reverse transcriptase inhibitors (NRTIs) and a protease inhibitor (PI) is prescribed for a patient with HIV infection who has a CD4⁺T cell count of <400/µL. the patient asks why so many drugs are necessary for treatment. The nurse explains that the primary rationale for combination therapy is that:
a)cross-resistance between specific antiretroviral drugs is reduced when drugs are given in combination b)combinations of antiretroviral drugs decrease the potential for development of antiretroviral-resistant HIV variants c)side effects of the drugs are reduced when smaller doses of three different drugs are used rather than large doses of one drug d)when CD4⁺T cell counts are <500/µL, a combination of drugs that have different actions is more effective in slowing HIV growth |
B
The use of potent combination antiretroviral therapy limits the potential for selection of antiretroviral-resistant HIV variants, the major factor limiting the ability of antiretroviral drugs to inhibit virus replication and delay disease progression. The drugs selected should be ones with which the patient has not been previously treated and that are not cross-resistant with antiretroviral agents previously used by the patient. |
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One of the most significant factors in determining when to start antiretroviral therapy in a patient with HIV infection is:
a)whether the patient has high levels of HIV antibodies b)the confirmation that the patient has contracted HIV infection c)the patient’s readiness to commit to a complex, life-long, uncomfortable drug regimen d)whether the patient has a support system to help manage the costs and side effects of the drugs |
C
Guidelines for initiating antiretroviral therapy (ART) are currently in a state of flux because of the development of alternative drugs and problems with long-term side effects and compliance with regimens. In the past, ART was always recommended at the time of HIV infection diagnosis, but today new guidelines suggest that treatment can be delayed until higher levels of immune suppression are observed. Whenever treatment is started, an important consideration is the patient’s readiness to initiate ART because adherence to drug regimens is a critical component of the therapy. |
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After teaching a patient with HIV infection about using antiretroviral drugs, the nurse recognizes that further teaching is needed when the patient says:
a)“I should never skip doses of medications, even if I develop side effects” b)“If my viral load becomes undetectable, I will no longer be able to transmit HIV to others” c)“I should not use any over-the-counter drugs without checking with my health care provider” d)“If I develop a constant headache that is not relieved with aspirin or acetaminophen, I should report it within 24 hours” |
B
An undetectable viral load in the blood does not mean that the virus is gone-it is still present in lymph nodes and other organs. Transmission is still possible, and the use of protective measures must be continued. |
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Prophylactic measures that are routinely used as early as possible in HIV infection to prevent opportunistic and debilitating secondary problems include administration of:
a)isoniazid (INH) to prevent tuberculosis b)trimethoprim-sulfamethoxazole (TMP-SMX) for toxoplasmosis c)vaccines for pneumococcal pneumonia, influenza, and hepatitis A&B d)varicella-zoster immune globulin (VZIG) to prevent chicken pox or shingles |
C
Pneumococcal, influenza, and hep A&B vaccines should be given as early as possible in HIV infection while there is still immunologic function. Isoniazid (NH) is used for 9-12 months only if a patient has reactive purified protein derivative (PPD)>5mm, has had high-risk exposure, or has prior intreated positive PPD. Trimethoprim-sulfmethoxazole (TMP-SMX) is initiated when CD4⁺T cells are <200/µL or when there is a history of PCP, and varicella-zoster immune globulin (VZIG) is indicated only after a significant exposure to chickenpox or shingles in patients with no history of disease or negative varicella-zoster virus (VZV) antibody test. |
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A patient identified as HIV-antibody-positive 1 year ago manifests early HIV infection but does not want to start antiretroviral therapy at this time. An appropriate nursing intervention for the patient at this stage of illness is to:
a)assist with end-of-life issues b)provide care during acute exacerbations c)provide physical care for chronic diseases d)educate the patient regarding immune enhancement |
D
After a patient has positive HIV-antibody testing and is in early disease, the overriding goal is to keep the viral load as low as possible and to maintain a functioning immune system. The nurse should provide education regarding ways to enhance immune function to prevent the onset of opportunistic diseases in addition to teaching about the spectrum of the infection, options for care, signs and symptoms to watch for and ways to adhere to treatment regimens. |
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A patient with advanced AIDS has diarrhea and wasting syndrome. An appropriate nursing diagnosis for the patient is:
a)diarrhea related to opportunistic infection b)risk for fluid volume deficit related to diarrhea c)risk for infection related to immunosuppression d)risk for impaired skin integrity related to altered nutritional status and frequent stools |
D
The nursing diagnosis addresses a nursing problem that occurs as a result of the diarrhea and wasting and is a problem that nursing can treat. |
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A patent with advanced AIDS has a nursing diagnosis of impaired memory related to neurologic changes. In planning care for the patient, the nurse sets the highest priority on:
a)maintaining a safe patient environment b)providing a quiet, nonstressful environment to avoid overstimulation c)using memory cues such as calendars and clocks to promote orientation d)providing written instructions of directions to promote understanding and orientation |
A
All the nursing interventions are appropriate for a patient with impaired memory, but the priority is safety of the patient when cognitive and behavioural problems impair the ability to maintain a safe environment. |
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Failure of the sodium-potassium pump during severe protein depletion may lead to:
a)ascites b)anemia c)hyperkalemia d)hypoalbuminemia |
C
The sodium-potassium exchange pump uses 20-50% of all calories ingested. When energy sources are decreased, the pump fails to function, sodium is left in the cell, and potassium remains in extracellular fluids. Hyperkalemia, as well as hyponatremia, occurs. |
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During assessment of the patient with protein-calories malnutrition, the nurse would expect to find (all that apply):
a)decreased bowel sounds b)prominent bony structures c)a flat or concave abdomen d)cool, rough, dry, scaly skin e)decreased reflexes and inattention |
A, B, D, E
In malnutrition, metabolic processes are slowed, leading to increased sensitivity to cold, slowed heart rate and cardiac output, and decreased neurologic function. Because of slowed GI motility and absorption, the abdomen becomes distended and protruding, bowel sounds are decreased. Skin is rough, dry, and scaly whereas bone structures protrude because of muscle loss. |
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The nurse determines that the patient with the highest risk for the nursing diagnosis of imbalanced nutrition-less than body requirements related to decreased ingestion is the patient with:
a)TB infection b)malabsorption syndrome c)draining decubitus ulcers d)severe anorexia resulting from radiation therapy |
D
Malnutrition that results from a decreased intake of food is most common in individuals with severe anorexia that decreases the desire to eat. Infections create a hypermetabolic state that increases nutritional demand, malabsorption causes loss of nutrients that are ingested, and draining decubitus ulcers are examples of disorders that cause both loss of protein and hypermetabolic states. |
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The nurse monitors the lab results if the patient with protein-calorie malnutrition during treatment. An indication of improvement in the patient’s condition is:
a)decreased lymphocytes b)increased serum potassium c)increased serum transferring d)increased serum prealbumin |
C
Serum transferring is a protein that is synthesized by the liver and used for iron transport and decreases when there is protein deficiency. An increase in the protein would indicate a more positive nitrogen balance with amino acids available for synthesis. Decreased lymphocytes and serum albumin are indicators of protein depletion, and increased serum potassium shows continuing failure of the sodium-potassium pump. |
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To evaluate the effect of nutritional interventions with a patient with protein-calorie malnutrition, the best indicator for the nurse to use is the patient’s:
a)height and weight b)BMI c)weight in relation to ideal body weight d)mid-upper arm circumference and triceps skinfold |
D
Anthropometric measurements, including mid-upper arm circumference and triceps skinfold measurements, are good indicators of lean body mass and skeletal protein reserves and are valuable in evaluating persons who may have or are being treated for acute protein malnutrition. The other measurements do not specifically address muscle mass. |
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The nurse evaluates that patient teaching about a high-calorie, high-protein diet has been effective when the patient selects for breakfast from the hospital menu:
a)2 poached eggs, hash brown potatoes, and whole milk b)2 slices of toast with butter and jelly, OJ, and skim milk c)3 pancakes with butter and syrup, 2 slices of bacon, and apple juice d)cream of wheat with 2tbsp skim milk powder, one-half grapefruit, and high-protein milkshake |
A
The breakfast with the eggs provides 24g protein, compared with 14g for the protein-fortified cream of wheat and milkshake breakfast. Whole milk instead of skim helps meet the calorie requirements. The toast breakfast has 10g of protein, and the pancakes have about 6g. Bacon is considered a fat rather than a meat serving. |
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When teaching the older adult about nutritional needs during aging, the nurse emphasizes that:
a)the need for all nutrients decreases as one ages b)fewer calories, but the same amount of protein, are required as on ages c)fats, carbs, and protein should be decreased, but vitamin and mineral intake should be increased d)high-calorie oral supplements should be taken between meals to ensure that recommended nutrient needs are met |
B
Although caloric intake should be decreased in the older adult because of decreased activity and basal metabolic rate, the need for specific nutrients, such as proteins and vitamins, does not change. |
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When planning nutritional interventions for a healthy 83yo man, the nurse recognizes that the factor most likely to affect his nutritional status is:
a)living alone on a fixed income b)changes in cardiovascular function c)an increase in GI motility and absorption d)snacking between meals, resulting in obesity |
A
Socioeconomic conditions frequently have the greatest effect on the nutritional status of the healthy older adult. Limited income and social isolation can result in the ‘tea and toast’ meals of the older adult. |
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When considering tube feedings for a patient with severe protein-calorie malnutrition, the nurse knows that an advantage of a gastrostomy tube over an NG tube is that:
a)there is less irritation to the nasal and esophageal mucosa b)the patient experiences the sight and smells associated with eating c)aspiration resulting from reflux of formulas into the esophagus is less common d)routine checking for placement is not required because gastrostomy tubes do not become displaced |
A
Standard NG tubes are used for tube feedings for short-term feeding problems because prolonged therapy can result in irritation and erosion of the mucosa of the upper GI tract. Gastric reflux and the potential for aspiration can occur with both tubes that deliver fluids into the stomach. Both NG and gastrostomy tubes can become displaced and deprive the patient of the sensations associated with eating. |
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Before administering a bolus of intermittent tube feeding to a patient with a percutaneous endoscopic gastrostomy (PEG), the nurse aspirates 220ml of gastric contents. The nurse should:
a)return the aspirate to the stomach and recheck the volume of aspirate in an hour b)return the aspirate to the stomach and continue with the tube feeding as planned c)discard the aspirate to prevent overdistending the stomach when the new feeding is given d)notify the health care provider that the feedings have been scheduled too frequently to allow for stomach emptying |
B
<250ml residual does not require further action. |
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An indication for parenteral nutrition that is not appropriate for enteral tube feedings is:
a)head and neck cancer b)hypermetabolic states c)malabsorption syndrome d)protein-calorie malnutrition |
C
In malabsorption syndromes, foods that are ingested into the intestinal tract cannot be digested or absorbed, and tube feedings infused into the intestinal tract would also not be absorbed, all the other conditions can be treated with enteral or parenteral nutrition, depending on the patient’s needs. |
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The nurse is caring for a patient receiving 1000ml of PN solution over 24h. When is it time to change the solution, 150ml remain in the bottle. The most appropriate action by the nurse is to:
a)hang the new solution and discard the unused solution b)notify the health care provider for instructions regarding the infusion rate c)open the IV line and infuse the remaining solution as quickly as possible d)wait to change the solution until the remaining solution infuses at the prescribed rate |
A
Bacterial growth occurs at room temperature in nutritional solutions; therefore, solutions must not be infused for longer than 24h. Remaining solutions should be discarded. Speeding up the solution may cause hyperglycemia and should not be done. |
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An 18yo female patient with anorexia nervosa is admitted to the hospital for treatment. On admission she weighs 82lb (37kg) and is 5ft 3in (134.6cm). Her laboratory test results include the following: K⁺ 2.8mEq/L (2.8mmol/L), Hb 8.9g?dL (89g/L), and BUN 64mg/dL (22.8mmol/L). In planning care for the patient, the nurse gives the highest priority to the nursing diagnosis of:
a)risk for injury related to dizziness and weakness resulting from anemia b)risk for decreased CO related to dysrhythmias resulting from hypokalemia c)imbalanced nutrition: less than body requirements related to inadequate food intake d)risk for impaired urinary elimination related to elevated BUN resulting from renal failure |
B
The potential life-threatening cardiac complications related to the hypokalemia are the most important considerations in the patient’s care. The other nursing diagnoses are important considerations in the patient’s care but do not pose the immediate risk that the hypokalemia does. |
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_____ is the amount of oxygen bound to hemoglobin in comparison with the amount of oxygen the hemoglobin can carry, expressed in _____
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Arterial oxygen saturation (SaO) as a %
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_____ is the amount of oxygen dissolved in plasma and is expressed as a percentage
|
Partial pressue of oxygen (PaO₂) in mmHg
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If hemoglobin is _____, more oxygen is released from the hemoglobin to provide oxygen to the tissues
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Desaturated of oxygen
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The oxygen-hemoglobin dissociation curve indicates that a patient is adequately oxygenated when PaO₂ is above 60mmHg because at this point hemoglobin O₂ saturation _____
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Remains above 90%
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A patient has an oxyhemoglobin saturation of 90%. On the normal oxygen-hemoglobin dissociation curve with this saturation, he would have a PaO₂of about _____
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65mmHg
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When providing oxygen therapy to a patient with a shift to the right in the oxygen-hemoglobin dissociation curve caused by acidosis:
a)low concentrations of oxygen are administered because more oxygen is delivered to the tissues b)high concentrations of oxygen are necessary because blood picks up less oxygen from the lungs c)low concentrations of oxygen are administered because blood picks up more oxygen from the lungs d)high concentrations of oxygen may be administered to compensate for decreased unloading of oxygen in tissues |
A
When the oxygen-hemoglobin curve shifts to the right, blood picks up less oxygen from the lungs but delivers oxygen more readily to the tissues; thus, low concentrations of oxygen may be given to prevent oxygen toxicity. Shifts to the right occur with acidosis, hyperthermia, and increased PaCO₂. Alkalosis, hypothermia and decreases in PaCO₂ cause a leftward shift of the oxygen-hemoglobin curve, which may be treated with higher concentrations of oxygen to compensate for decreased oxygen unloading in the tissues. |
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A patient with a SaO₂ of 85% has a PaO₂ of 50mmHg. This indicates a:
a)shift to the left in the oxygen-hemoglobin dissociation curve that could be caused by acidosis b)shift to the right in the oxygen-hemoglobin dissociation curve that could be caused by alkalosis c)shift to the left in the oxygen-hemoglobin dissociation curve that could be caused by hypothermia d)shift to the right in the oxygen-hemoglobin dissociation curve that could be caused by hyperthermia |
C
Normally, an SaO₂ of 85% correlates with a PaO₂ of about 60mmHg. In a leftward shift of the oxygen-hemoglobin curve, oxygen is less readily delivered to the tissues and a lower PaO₂ is present. In a rightward shift of the curve, an SaO₂ of 85% would reflect a higher PaO₂ than normal, about 65mmHg. Leftward shifts are commonly caused by alkalosis, hypothermia, and decreases in PaCO. |
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A 75yo patient breathing room air has the following ABG results: pH 7.40; PaO₂ 72mmHg; SaO₂ 92%; PaCO₂ 40mmHg. An appropriate action by the nurse is to:
a)document the results in the patient’s record b)repeat the ABGs within an hour to validate the findings c)encourage deep breathing and coughing to open the alveoli d)initiate pulse oximetry for continuous monitoring of the patient’s oxygen status |
A
Normal findings in ABGs in the older adult include a decreased PaO₂ and SaO₂ but normal pH and PaCO₂. No interventions are necessary for these findings. Usual PaO₂ levels are expected in patients ≤60yo or younger. |
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A patient’s ABGs includea PaO₂ of 88mmHg and a PaCo₂ of 38mmHg, and mixed venous blood gases include a PvO₂ of 40mmHg and PvCO₂ of 46mmHg. These findings indicate that the patient has:
a)impaired cardiac output b)unstable hemodynamics c)inadequate delivery of oxygen to the tissues d)normal capillary oxygen-carbon dioxide exchange |
D
Normal venous blood gas values reflect the normal uptake of oxygen from arterial blood and the release of carbon dioxide from cells into the blood, resulting in a much lower PaO₂ and an increased PaCO₂. The pH is also decreased in mixed venous blood gases because of the higher PvCO₂. Normal mixed venous blood gases also have much lower PvO₂ and SvO₂ than arterial blood gases. Mixed venous blood gases are used when patients are hemodynamically unstable to evaluate the amount of oxygen delivered to the tissues and the amount of oxygen consumed by the tissues. |
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A pulse oximetry monitor indicates that the patient has a drop in SpO₂ from 95% to 85% over several hours. The first action the nurse should take is to:
a)order stat ABGs to confirm the SpO₂ with a SaO₂ b)notify the health care provider of the change in baseline PaO₂ c)check the position of the probe on the finger or earlobe d)start oxygen administration by nasal cannula at 2L/min |
C
Pulse oximetry is inaccurate of the probe is loose, if there is low perfusion, or when skin colour is dark; before other measures are taken, the nurse should check the probe site. If the probe is intact at the site and perfusion is adequate, an ABG analysis should be done to verify accuracy and oxygen may be administered, depending on the patient’s condition and the assessment of respiratory and cardiac status. |
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Pulse oximetry may not be a reliable indicator of oxygen saturation in the patient:
a)with a fever b)who is anesthetized c)in hypovolemic shock d)receiving oxygen therapy |
C
Poor peripheral perfusion that occurs with hypovolemia or other types of conditions that cause peripheral vasoconstriction will cause inaccurate pulse oximetry, and ABGs may need to be used to monitor oxygenation status and ventilation status in these patients. It would not be affected by fever or anesthesia and is method of monitoring arterial oxygen saturation in patients receiving oxygen therapy. |
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A patient has an SpO₂of 70%. What are four other assessments the nurse should consider in making a judgement about the adequacy of the patient’s oxygenation?
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1-How the patient’ SpO₂ compares with the expected normal values?
2-The trend and rateof development of the hypoxemia 3-The presence of other signs and symptoms of inadequate oxygenation 4-What the oxygenation status is with activity or exercise |
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Criteria for the use of continuous oxygen therapy include:
a)SpO₂ of 95%, PaO₂ of 70mmHg b)SpO₂ of 90%, PaO₂ of 60mmHg c)SpO₂ of 88%, PaO₂ of 55mmHg d)SpO₂ of 75%, PaO₂ <40mmHg |
C
An SpO₂ of 88% and a PaO₂ of 55mmHg indicate inadequate oxygenation and are the criteria for prescription of continuous oxygen therapy. These values may be adequate for patients with chronic hypoxemia if no cardiac problems occur but will affect their activity intolerance |
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An excess of carbon dioxide in the blood causes an increased respiratory rate and volume because:
a)CO₂ displaces oxygen on hemoglobin, leading to a decreased PaO₂ b)CO₂ causes an increase in the amount of hydrogen ions available in the body c)CO₂ combines with water to form carbonic acid, lowering the pH of cerebrospinal fluid d)CO₂ directly stimulates chemoreceptors in the medulla to increase respiratory rate and volume |
C
A combination of excess CO₂ and H₂O results in carbonic acid, which lowers the pH of the cerebrospinal fluid and stimulates an increase in the respiratory rate. Peripheral chemoreceptors in the carotid and aortic bodies also respond to increases in PaCO₂ to stimulate the respiratory center. Excess CO₂ does not increase the amount of hydrogen ions available in the body but does combine with the hydrogen of water to form an acid. |
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The respiratory defense mechanism that is most impaired by smoking is:
a)filtration of air b)the cough reflex c)mucociliary clearance d)reflex bronchoconstriction |
C
Ciliary action impaired by smoking and increased mucus production may be caused by the irritants in tobacco smoke, leading to impairment of the mucociliary clearance system. Smoking does not directly affect filtration, the cough reflex, or reflex bronchoconstriction, but it does impair the respiratory defense mechanism provided by alveolar macrophages. |
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The presence of bronchovesicular breath sounds in the peripheral lung fields is described as:
a)rhonchi b)crackles c)adventitious sounds d)abnormal lung sounds |
D
Bronchovesicular breath sounds are normal breath sounds when they are heard anteriorly over the main-stem bronchi on either side of the sternum and posteriorly between the scapulas. If they are heard in the peripheral lung fields, they are considered abnormal breath sounds. Adventitious lung sounds are extra abnormal sounds that include crackles, rhonchi, wheezes, and pleural friction rubs. |
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Finger clubbing
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Chronic hypoxemia
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Stridor
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Partial obstruction of trachea or larynx
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Wheezes
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Bronchoconstriction
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Pleural friction rub
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Pleurisy
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Increased tactile fremitus
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Lung consolidation with fluid or exudate
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Hyperresonance
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Air trapping
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Fine crackles
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Interstitial filling with fluid
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Absent breath sounds
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Atelectasis
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A nurse has been exposed to TB during care of a patient with TB and has TB skin testing performed. The nurse is considered uninfected if:
a)there is no redness or induration at the injection site b)there is an induration of only 5mm at the injection site c)testing causes a 10mm reddened flat area at the injection site d)a negative skin test is followed by another negative skin test in 3 weeks |
D
Because antibody production in response to infection with the TB bacillus may not be sufficient to produce a reaction to TB skin testing immediately after infection, two-step testing is recommended for individuals likely to be tested often, such as health care providers. An initial negative skin test should be repeated in 1-3 weeks, and if the second test is negative, the individual can be considered uninfected. All other answers indicate a negative response to skin testing but, as single testing, do not allow for delay in antibody production. |
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A primary nursing responsibility after obtaining a blood specimen for ABGs is:
a)adding heparin to the blood specimen b)applying pressure to the puncture site for 2 full minutes c)taking the specimen immediately to the lab in an iced container d)avoiding any changes in oxygen intervention for 20 minutes following the procedure |
C
Samples for ABGs must be iced to keep the gases dissolved in the blood (unless the specimen is to be analyzed in <1min) and taken directly to the lab. The syringe used to obtain the specimen is taken, and pressure is applied to the arterial puncture site for 5 min after obtaining the specimen. Changes in oxygen therapy or interventions should be avoided for 20mins before the specimen is drawn because the changes might alter blood gas values. |
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When preparing a patient for a pulmonary angiogram scan, the nurse:
a)assess the patient for iodine allergy b)implements NPO orders for 6-12 hours before the test c)ensures that informed consent has been obtained from the patient d)informs the patient that radiation isolation for 24 hours after the test is necessary |
A
A pulmonary angiogram involves the injection of an iodine-based radiopaque dye into the pulmonary artery or the right side of the heart, and iodine or shellfish allergies should be assessed before injection. A bronchoscopy, mediastinostomy, or biopsies-require informed consent. Nuclear scans use radioactive materials for diagnosis, but the amounts are very small, and no radiation precautions are indicated for the patient. |
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To prepare the patient for a thoracentesis, the nurse positions the patient:
a)side-lying with the affected side up b)flat in the bed with the arms extended out to the side c)sitting upright with the elbows on an over-the-bed table d)in semi-Fowler’s position with the arms above the head |
C
To prevent damage to the lung tissue and to facilitate entry into the pleural cavity, the patient undergoing a thoracentesis is seated upright with the elbows or arms on an over-the-bed table. |
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The nurse observes the patient for symptoms of a pneumothorax following a:
a)thoracentresis b)ventilation-perfusion scan c)pulmonary function test d)positron emission tomography scan |
C
The greatest chance of a pneumothorax occurs with a thoracentesis because of the possibility of lung-tissue injury during this procedure. A ventilation-perfusion scan and PET involves injections, but no manipulation of the respiratory tract is involved. Pulmonary function tests are noninvasive. |
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The nurse care provider orders a pulmonary angiogram for a patient admitted with dyspnea and hemoptysis. The nurse recognizes that this test is most commonly used to diagnose:
a)TB b)cancer of the lung c)airway obstruction d)pulmonary embolism |
D
A pulmonary angiogram outlines the pulmonary vasculature and is useful to diagnose obstructions or pathologic conditions of the pulmonary vessels, such as pulmonary embolus. The tissue changes of TB and cancer of the lung may be diagnosed by chest x-ray, CT, MRI, or PET. Airway obstruction is most often diagnosed with pulmonary function testing. |
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Vt
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Volume of air inhaled and exhaled with each breath
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RV
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Amount of air remaining in lungs after forced expiration
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TLC
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Maximum amount of air lungs can contain
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VC
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Maximum amount of air that can be exhaled after maximum inhalation
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FVC
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Amount of air that can be quickly and forcefully exhaled after maximum inspiration
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PEFR
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Maximum rate of airflow during forced expiration
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FEV₁
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Amount of air exhaled in first second of forced vital capacity
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FRC
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Volume of air in lungs after normal exhalation
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Respiratory failure can be defined as:
a)the absence of ventilation b)any episode in which part of the airway is obstructed c)inadequate gas exchange to meet the metabolic needs of the body d)an episode of acute hypoxemia caused by a pulmonary dysfunction |
C
Respiratory failure results when the transfer of oxygen or carbon dioxide function of the respiratory system is impaired, and although the definition by PaO₂ and PaCO₂ levels, the major factor in respiratory failure is inadequate gas exchange to meet tissue O₂ needs. Absence of ventilation is respiratory arrest, and partial airway obstruction may not necessarily cause respiratory failure. Acute hypoxemia may be caused by factors other than pulmonary dysfunction. |
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|
Primary problem is inadequate oxygen transfer
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Hypoxemic Respiratory Failure
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Most often caused by V/Q mismatch and shunt
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Hypoxemic Respiratory Failure
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Referred to as ventilator failure
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Hypercapnic Respiratory Failure
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Exists when PaO₂is 60mmHg or less, even when oxygen is administered at 60%
|
Hypoxemic Respiratory Failure
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|
Risk of inadequate oxygen saturation of hemoglobin exists
|
Hypoxemic Respiratory Failure
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|
The body is unable to compensate for academia of increased PaO₂
|
Hypercapnic Respiratory Failure
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|
Primary problem is insufficient carbon dioxide removal
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Hypercapnic Respiratory Failure
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|
Referred to as oxygenation failure
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Hypoxemic Respiratory Failure
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|
Results from an imbalance between ventilatory supply and ventilator demand
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Hypercapnic Respiratory Failure
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A V/Q ratio of 1:1 (V/Q=1) reflects an _____ of 4-5L that is mismatched by 4-5L of _____ to the lungs each minute
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Alveolar ventilation,
Blood flow |
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The V/Q ratio is _____ when there is less ventilation to an area of the lung than perfusion
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1 or less
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An extreme V/Q imbalance resulting from blood leaving the heart without being exposed to ventilated areas of the lung is known as _____
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A shunt
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An intrapulmonary shunt occurs when an obstruction impairs the flow of _____
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Air in the lung from passing into the blood
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In differentiating between a V/Q mismatch and an intrapulmonary shunt, an increase in PaO₂, on oxygen administration occurs in the patient with _____
|
V/Q mismatch
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Gas transport is slowed in _____, resulting in exertional hypoxemia that is not present at rest
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Diffusion limitation
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V/Q mismatch of 1 or greater
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Pulmonary embolism
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V/Q mismatch of 1 or less
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Atelectasis
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Anatomic shunt
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Ventricular septal defect
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Intrapulmonary shunt
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Pulmonary edema
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Diffusion limitation
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Pulmonary fibrosis
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V/Q mismatch
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Decreased alveolar ventilation from obstruction of bronchioles and terminal respiratory units
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Diffusion limitation
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Thickening of alveolar-capillary membrane from secretions and fluid accumulation
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Shunt
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Consolidation of lung lobules with exudates and alveolar collapse
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Alveolar hypoventilation
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Pleuritic pain and inflammation
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Hypercapnic respiratory failure is most likely to occur in the patient who has:
a)rapid, deep respirations in response to pneumonia b)slow, shallow respirations as a result of sedative overdose c)large airway resistance as a result of severe bronchospasm d)poorly ventilated areas of the lung caused by pulmonary edema |
B
Hypercapnic respiratory failure is associated with alveolar hypoventilation with increases in alveolar and arterial CO₂ and often is caused by problems outside the lungs. A patient with slow, shallow respirations is not exchanging enough gas volume to eliminate CO₂. Deep, rapid respirations reflect hyperventilation and often accompany lung problems that cause hypoxemic respiratory failure. Pulmonary edema and large airway resistance cause obstruction of oxygenation and result in a V/Q mismatch or shunt typical of hypoxemic respiratory failure. |
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Acute respiratory failure in a patient with chronic lung disease would most likely be indicated by ABG results of:
a)PaO₂ 52mmHg, PaCO₂ 56mmHg, pH 7.4 b)PaO₂ 46mmHg, PaCO₂ 52mmHg, pH 7.36 c)PaO₂ 48mmHg, PaCO₂ 54mmHg, pH 7.38 d)PaO₂ 50mmHg, PaCO₂ 54mmHg, pH 7.28 |
D
In a patient with normal lung function, respiratory failure is commonly defined as a PaO₂ ≤60mmHg or a PaCO₂≥45mmHg or both, but because the patient with chronic pulmonary disease normally maintains low PaO₂ and high PaCO₂, acute respiratory failure in these patients can be defined as an acute decrease in PaO₂ or increase in PaCO₂ from the patient’s baseline parameters, accompanied by an acid pH. The pH of 7.28 reflects acidemia and a loss of compensation in the patient with chronic lung disease. |
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Cyanosis
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Hypoxemic Respiratory Failure
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|
Morning headache
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Hypercapnic Respiratory Failure
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|
Rapid, shallow respirations
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Hypercapnic Respiratory Failure
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Metabolic acidosis
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Hypoxemic Respiratory Failure
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|
“Three word” dyspnea
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Hypoxemic Respiratory Failure
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Use of tripod position
|
Hypercapnic Respiratory Failure
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Respiratory acidosis
|
Hypercapnic Respiratory Failure
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The nurse detects the early onset of hypoxemia in the patient who experiences:
a)restlessness b)hypotension c)central cyanosis d)cardiac dysrhythmias |
A
Because the brain is very sensitive to a decrease in oxygen delivery, restlessness, agitation, disorientation, and confusion are early signs of hypoxemia, for which the nurse should be alert. Mild hypertension is also an early sign, accompanied by tachycardia. Central cyanosis is an unreliable, late sign of hypoxemia, and cardiac dysrhythmias also occur later. |
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The nurse assesses that a patient in respiratory distress is developing respiratory fatigue and the risk of respiratory arrest when the patient:
a)cannot breathe unless he is sitting upright b)uses the abdominal muscles during expiration c)has an increased inspiratory/expiratory (I/E) ratio d)has a change in respiratory rate from rapid to slow |
D
The increase in respiratory rate required to blow off accumulated CO₂ predisposes to respiratory muscle fatigue, and the slowing of a rapid rate in a patient in acute distress indicates tiring and the possibility of respiratory arrest unless ventilator assistance is provided. A decreased I/E ratio, orthopnea, and accessory muscle use is common findings in respiratory distress but do not necessarily signal respiratory fatigue or arrest. |
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A patient has a PaO₂ 50mmHg and a PaCO₂ 42mmHg because of an intrapulmonary shunt. The patient is most likely to respond best to:
a)positive pressure ventilation b)oxygen administration at a FiO₂ of 100% c)administration of oxygen per nasal cannula at 1-3L/min d)clearance of airway secretions with coughing and suctioning |
A
Patients with a shunt are usually more hypoxemic that are patients with a V/Q mismatch because the alveoli are filled with fluid, which prevents gas exchange. Hypoxemia resulting from intrapulmonary shunt is usually not responsive to high O₂ concentrations, and the patient will usually require positive pressure ventilation. Hypoxemia associated with a V/Q mismatch usually responds favourably to oxygen administration at 1-3L/min by nasal cannula. Removal of secretions with coughing and suction is not generally effective in reversing an acute hypoxemia resulting from a shunt. |
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A patient with a massive hemothorax and pneumothorax has absent breath sounds in the right lung. To promote improved V/Q matching, the nurse positions the patient:
a)on the left side b)on the right side c)in a reclining chair bed d)supine with the HOB elevated |
A
When there is impaired function of the one lung, the patient should be positioned with the unaffected lung in the dependent position to promote perfusion to the functioning tissue. If the diseased lung is positioned dependently, more V/Q mismatch will occur. The HOB may be elevated, or a reclining chair may be used, with the patient positioned on the unaffected side, to maximize thoracic expansion if the patient has increased work of breathing. |
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A patient in hypercapnic respiratory failure has a nursing diagnosis of ineffective airway clearance related to increasing exhaustion. An appropriate nursing intervention for the patient includes:
a)inserting an oral airway b)performing augmented coughing c)teaching the patient “huff” coughing d)teaching the patient slow pursed-lip breathing |
B
Augmented coughing by applying pressure on the thorax or abdominal muscles at the beginning of expiration helps to produce muscle movement, increases pleural pressure and expiratory flows, and assists the cough to remove secretions in the patient who is exhausted. An oral airway is used only if there is a possibility that the tongue will obstruct the airway. Huff coughing is indicated for patients with problems with ET tubes in place, which prevent glottal closure, and slow, pursed-lip breathing is used to prevent air trapping and give the patient a sense of control over breathing. |
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After endotracheal intubation and mechanical ventilation have been started, patient in respiratory failure becomes very agitated and is breathing asynchronously with the ventilator. It is most important for the nurse to first:
a)evaluate the patient’s pain level, ABGs, and electrolyte values b)sedate the patient to unconsciousness to eliminate patient awareness c)administer the PRN vecuronium (Norcuron) to promote synchronous ventilations d)slow the rate of ventilations provided by the ventilator to allow for spontaneous breathing by the patient |
A
Although sedation, analgesic, and neuromuscular blockage are often used to control agitation and pain, these treatments may contribute to prolonged ventilator days. It is most important to assess the patient for the cause of the restlessness and agitation (i.e. pain, hypoxemia, electrolyte imbalances), and treat the underlying cause before sedating the patient more. |
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|
Hemodynamic monitoring is instituted in severe respiratory failure primarily to:
a)detect V/Q mismatches b)continuously measure the arterial BP c)evaluate oxygenation and ventilation status d)evaluate cardiac status and blood flow to tissues |
D
Hemodynamic monitoring with a pulmonary artery catheter is instituted in severe respiratory failure to determine the amount of blood flow to tissues and the response of the lung and heart to hypoxemia. Continuous BP monitoring may be performed, but BP is a reflection of cardiac activity, which can be determined by the pulmonary artery catheter findings. ABGs are important to evaluate oxygenation and ventilation status and V/Q mismatches. |
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|
In caring for a patient in ARF, the nurse recognizes that noninvasive positive-pressure ventilation (NIPPV) may be indicated for a patient who:
a)is comatose and has high oxygen requirements b)has copious secretions that require frequent suctioning c)responds to hourly bronchodilator nebulization treatments d)is alert and cooperative but has increasing respiratory exhaustion |
D
Noninvasive positive-pressure ventilation (NIPPV) involves the application of a face mask and delivery of air under inspiratory pressure. Because the device is worn externally, the patient must be able to cooperate in its use, and frequent access to the airway for suctioning or inhaled medications must not be necessary. It is not indicated when high levels of oxygen are needed or respirations are absent. |
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Although acute respiratory distress syndrome (ARDS) may result from direct lung injury or indirect lung injury as a result of systemic inflammatory response syndrome (SIRS), the nurse is aware that ARDS is most likely to occur in the patient with a host insult resulting from:
a)septic shock b)oxygen toxicity c)multiple trauma d)prolonged hypotension |
A
Although ARDS may occur in the patient who has virtually any severe illness or trauma and may be both a cause and result of SIRS, the most common precipitating insults of ARDS are septic shock and gastric aspiration. |
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Three primary changes that occur in the injury or exudative phase of ARDS:
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1-Interstitial and alveolar edema from damage to vascular endothelium and increased capillary permeability
2-Atelectasis from destruction of type II cells, resulting in inactivation of surfactant 3-Hyaline membrane formation from exudation of high-molecular-weight substances in the edema fluid |
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Patients with ARDS who survive the acute phase of lung injury and who progress to the fibrotic stage manifest:
a)chronic pulmonary edema and atelectasis b)resolution of edema and healing of lung tissue c)continued hypoxemia because of diffusion limitation d)increased lung compliance caused by the breakdown of fibrotic tissue |
C
In the fibrotic phase of ARDS, diffuse scarring and fibrosis of the lungs occur, resulting in decreased surface area for gas exchange and continued hypoxemia caused by diffusion limitation. Although edema is resolved, lung compliance is decreased because of interstitial fibrosis, and long-term mechanical ventilation is required with a poor prognosis for survival. |
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In caring for the patient with ARDS, the most characteristic sign the nurse would expect the patient to exhibit is:
a)increased PAWP b)refractory hypoxemia c)bronchial breath sounds d)progressive hypercapnia |
B
Hypoxemia that does not respond to oxygenation by any route is a hallmark of ARDS and is always present. PaCO₂ levels may be normal until the patient is no longer able to compensate in response to the hypoxemia. Bronchial breath sounds may be associated with the progression of ARDS. Pulmonary capillary wedge pressures that are normally elevated in cardiogenic pulmonary edema are normal in the pulmonary edema of ARDS. |
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The nurse suspects the early stage of ARDS in any seriously ill patient who:
a)develops respiratory acidosis b)has diffuse crackles and rhonchi c)exhibits dyspnea and restlessness d)has a decreased PaO₂ and an increased PaCO₂ |
C
Early signs of ARDS are insidious and difficult to detect, but the nurse should be alert for any early signs of hypoxemia, such as restlessness, dyspnea, and decreased mentation, in patients who are at risk for ARDS. Abnormal findings on physical examination or diagnostic studies, such as adventitious lung sounds, signs of respiratory distress, respiratory alkalosis, or decreasing PaO₂, are usually indications that ARDS has progressed beyond the initial stages. |
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A patient with ARDS has a nursing diagnosis of risk for infection. To detect the presence of infections commonly associated with ARDS, the nurse monitors:
a)gastric aspirate for pH and blood b)the quality, quantity, and consistency of sputum c)for subcutaneous emphysema of the face, neck, and chest d)the mucous membranes of the oral cavity for open lesions |
B
Hospital-acquired pneumonia is one of the most common complications of ARDS, and early detection requires frequent monitoring of sputum smears and cultures and assessment of the quality, quantity, and consistency of sputum. Blood in gastric aspirate may indicate a stress ulcer, and subcutaneous emphysema of the face, neck, and chest occurs with barotraumas during mechanical ventilation. Oral infections may result from prophylactic antibiotics and impaired host defenses but are not common. |
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The best patient response to treatment of ARDS occurs when initial management includes:
a)treatment of the underlying condition b)administration of prophylactic antibiotics c)treatment with diuretics and mild fluid restriction d)endotracheal intubation and mechanical ventilation |
A
Because ARDS is precipitated by a physiologic insult, a critical factor in its prevention and early management is treatment of the underlying condition. Prophylactic antibiotics, treatment with diuretics and fluid restriction and mechanical ventilation are also used as ARDS progresses. |
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When mechanical ventilation is used for the patient with ARDS, PEEP is often applied to:
a)prevent alveolar collapse and open up collapsed alveoli b)permit smaller tidal volumes with permissive hypercapnia c)promote complete emptying of the lungs during exhalation d)permit extracorporeal oxygenation and carbon dioxide removal outside the body |
A
PEEP used with mechanical ventilation applies positive pressure to the airway and lungs at the end of exhalation, keeping the lung partially expanded and preventing collapse of the alveoli and helping to open up collapsed alveoli. Permissive hypercapnia is allowed when the patient with ARDS is ventilated with small tidal volumes to prevent barotraumas. Extracorporeal membrane oxygenation and extracorporeal CO₂ removal involve passing blood across a gas-exchanging membrane outside the body and then returning oxygenated blood back to the body. |
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The nurse suspects that a patient with PEEP is experiencing negative effects of this ventilatory maneuver upon finding a(n):
a)increasing PaO₂ b)decreasing HR c)decreasing blood pressure d)increasing central venous pressure (CVP) |
C
PEEP increases intrathoracic and intrapulmonary pressures, compresses the pulmonary capillary bed, and reduces blood return to both the right and left side of the heart. Preload (CVP) and CO are decreased, often with a dramatic decrease in BP. |
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Prone positioning is considered for a patient with ARDS who has not responded to other measures to increase PaO₂. The nurse knows that this strategy:
a)increases the mobilization of pulmonary secretions b)decreases the workload of the diaphragm and intercostal muscles c)promotes opening of atelectatic alveoli in the upper portion of the lung d)promotes perfusion of nonatelectatic alveoli in the anterior portion of the lung |
D
When a patient with ARDS is supine, alveoli in the posterior areas of the lung are dependent and fluid-filled, and the heart and mediastinal contents place more pressure on the lungs, predisposing to atelectasis. If the patient is turned prone, air filled, nonatelectasic alveoli in the anterior portion of the lung receive more blood, and perfusion may be better matched to ventilation, causing less V/Q mismatch. Lateral rotation therapy is used to stimulate postural drainage and help mobilize pulmonary secretions. |
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During assessment of the patient with a viral upper respiratory infection, the nurse recognizes that antibiotics may be indicated based on the findings of:
a)cough and sore throat b)copious nasal discharge c)dyspnea and purulent sputum d)100°F (38°C) temperature |
C
Dyspnea and purulent sputum in a patient who has a viral upper respiratory infection (URI) indicate lower respiratory involvement and a possible secondary bacterial infection. Bacterial infections are indications for antibiotic therapy, but unless symptoms of complications are present, injudicious administration of antibiotics may produce resistant organisms. Elevated temperature, purulent nasal drainage, cough, sore throat, and myalgia are common symptoms of viral rhinitis and influenza. |
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A 36yo patient asks the nurse whether an influenza vaccine is necessary every year. The best response by the nurse is:
a)“You should get the live, attenuated flu vaccine that is inhaled nasally every year” b)“Only health care workers in contact with high-risk patients should be immunized each year” c)“Annual vaccination is not necessary because previous immunity will protect you for several years” d)“New antiviral drugs, such as zanamivir (Relenza), eliminate the need for vaccine except in the older adult” |
A
The injected, inactivated influenza vaccine is recommended for individuals at increased risk for influenza-related complications, such as people aged 50y and older, residents of long-term care facilities, adults with chronic diseases, health care workers, and providers of care to at-risk persons. The attenuated influenza vaccine is given intranassaly and is recommended for all healthy people between the ages of 5-49. Antiviral agents will help reduce the duration and severity of influenza in those at high risk, but immunization is the best control |
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Four symptoms that indicate to the nurse that the patient has a partial airway obstruction while being fed by the nurse:
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1-Stridor
2-Use of accessory muscles 3-Suprasternal and intercostals retractions 4-Wheezing |
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An advantage of a tracheostomy over an endotracheal tube for long-term management of an upper airway obstruction is that a tracheostomy:
a)is safer to perform in an emergency b)allows for more comfort and mobility c)has a lower risk of tracheal pressure necrosis d)is less likely to lead to lower respiratory tract infection |
B
With a tracheostomy (vs endotracheal [ET]), patient comfort is increased because there is no tube in the mouth; because the tube is more secure, mobility is improved. It is preferable to perform a tracheotomy in the OR because it requires careful dissection, but it can be performed with local anesthetic in the ICU or ER. With a cuff, tracheal pressure necrosis is as much a risk with a tracheostomy tube as with an ET, and infection is also as likely to occur because the defenses of the upper airway are bypassed. |
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During care of a patient with a cuffed tracheostomy, the nurse notes that the tracheostomy tube has an inner cannula. To care for the tracheostomy appropriately, the nurse:
a)deflates the cuff and removes and suctions the inner cannula b)removes the inner cannula and cleans the mucus from the tube c)removes the inner cannula if the patient shows signs of airway obstruction d)keeps the inner cannula in place at all times to prevent dislodging the tracheostomy tube |
B
An inner cannula is a second tubing that fits inside the outer tracheostomy tube and can be removed and cleaned of mucus that has accumulated on the inside of the tube. Many tracheostomy tubes today do not have inner cannulas because if humidification is adequate, accumulation of mucus should not occur. |
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Three precautions related to prevention of dislodgment of a tracheostomy tube the first several days after its placement:
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1-Keep a replacement tube of equal or smaller size at the bedside for emergency reinsertion
2-Tracheostomy tapes should not be changed the first 24h after insertion 3-The first tube change is performed no sooner than 7d after tracheostomy |
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Nursing care of the patient with a cuffed tracheostomy tube in place includes:
a)changing the tube every 3 days b)recording cuff pressure every 8 hours c)performing mouth care every 12 hours d)assessing arterial blood gases every 8 hours |
B
Cuff pressure should be monitored every 8h to ensure that an air leak around the cuff does not occur and that the pressure is not too high to allow adequate tracheal capillary perfusion. Tracheostomy tubes are not usually changed sooner than 7d after a tracheostomy. Mouth care should be performed a minimum of q8h and more often as needed to remove dried secretions. ABGs are not routinely assessed with tracheostomy tube placement unless symptoms of respiratory distress continue. |
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A patient’s tracheostomy tube becomes dislodged with vigorous coughing. The first action by the nurse is to:
a)attempt to replace the tube b)notify the health care provider c)place the patient in high Fowler’s position d)ventilate the patient with a manual resuscitation bag until the health care provider arrives |
A
If a tracheostomy tube is dislodged, the nurse should immediately attempt to replace the tube by grasping the retention sutures (if available) and spreading the opening. The obturator is inserted in the replacement tube, water-soluble lubricant is applied to the tip, and the tube is inserted in the stoma at a 45° angle to the neck. The obturator is immediately removed to provide an airway. If the tube cannot be reinserted, the health care provider should be notified, and the patient should be assessed for the level of respiratory distress, positioned in a semi-Fowler’s position, and ventilated with a manual bag only if necessary until assistance arrives. |
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To determine when the patient with a tracheostomy tube can effectively swallow, the nurse deflates the cuff and:
a)checks for a gag reflex at the back of the tongue with a tongue blade b)asks the patient to drink 30ml of milk and suctions the tube for coloured secretions c)has the patient swallow a small amount of water and observes for symptoms of respiratory distress d)has the patient drink a small amount of blue-coloured water, observing for coughing and coloured secretions |
D
If coloured secretions are coughed or suctioned from the trachea after the patient has attempted to swallow colored water, swallowing is probably not functional and aspiration has occurred. Uncoloured water is not discernible as aspirate, and aspiration of small amounts may not cause any respiratory symptoms. The presence of a gag reflex does not ensure that a patient can adequately swallow with a tracheostomy tube in place, and no fluids except clear liquids should be used to assess aspiration risk. |
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The classification of pneumonia as community-acquired pneumonia (CAP) or hospital-acquired pneumonia (HAP) is clinically useful because:
a)atypical pneumonia syndrome is more likely to occur in HAP b)diagnostic testing does not have to be used to identify causative agents c)causative agents can be predicted, and empiric treatment is often effective d)IV antibiotic therapy is necessary for HAP, but oral therapy is adequate for CAP |
C
Pneumonia that has its onset in the community us usually caused by different microorganisms than pneumonia that develops during hospitalization and treatment can be empiric-based on observations and experience without knowing the exact cause. In at least half the cases of pneumonia, a causative organism cannot be identified from cultures, and treatment is based on experience. |
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When obtaining a health history from a patient at the clinic with suspected CAP, the nurse expects the patient to report:
a)a dry, hacking cough b)a recent loss of consciousness c)an abrupt onset of fever and chills d)a gradual onset of headache and sore throat |
C
Community-acquired pneumonia (CAP) is most commonly caused by Staph… pneumonia and is associated with an acute onset with fever, chills, productive cough with purulent or bloody sputum, and pleuritic chest pain. Other causes of pneumonia have a more gradual onset with dry, hacking cough; headache; and sore throat. A recent loss of consciousness or altered consciousness is common in those pneumonias associated with aspiration, such as anaerobic bacterial pneumonia. |
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Initial antibiotic treatment for pneumonia is usually based on:
a)the severity of symptoms b)the presence of characteristic leukocytes c)Gram stains and cultures of sputum specimens d)history and physical examination and characteristics chest radiographic findings |
D
Prompt treatment of pneumonia with appropriate antibiotics is important in treating bacterial and mycoplasma pneumonia, and antibiotics are often administered on the basis of the history, physical examination, and a chest x-ray showing a typical pattern characteristic of a particular organism without further testing. Sputum and blood cultures take 24-72h for results, and microorganisms often cannot be identified with either Gram stains or cultures. Whether the pneumonia is CAP or HAP is more significant than the severity of symptoms. |
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After the health care provider sees a patient hospitalized with a stroke who developed a fever and adventitious lung sounds, the following orders are written. Which will the nurse implement first?
a)anterior/posterior and lateral chest x-rays b)start IV levofloxacin (Levaquin) 500mg q24h c)sputum specimen for gram stain and culture and sensitivity d)CBC with WBC count and differential |
C
A sputum specimen for Gram stain and culture should be done before initiating antibiotic therapy in a hospitalized patient with suspected pneumonia, and then antibiotics should be started without delay. Chest x-rays and blood cell tests will not be altered significantly by delaying the tests until after the first dose of antibiotics. |
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Following assessment of a patient with pneumonia, the nurse identifies a nursing diagnosis of impaired gas exchange is based on the findings of:
a)SpO₂ of 86% b)crackles in both lower lobes c)temperature of 101.4°F (38.6°C) d)production of greenish purulent sputum |
A
Oxygen saturation obtained by pulse oximetry should be between 90-100%. An SpO₂ lower than 90% indicates a hypoxemia and impaired gas exchange. Crackles, purulent sputum, and fever are all symptoms but do not necessarily relate to impaired gas exchange. |
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A patient is admitted to the hospital with fever, chills, a productive cough with rusty sputum, and pleuritic chest pain. Pneumonococcal pneumonia is suspected. An appropriate nursing diagnosis for the patient based on the patient’s manifestations is:
a)hyperthermia related to acute infectious process b)chronic pain related to ineffective pain management c)risk for injury related to disorientation and confusion d)ineffective airway clearance related to retained secretions |
A
The patient with pneumonococcal pneumonia is acutely ill with fever and the systemic manifestations of fever, such as chills, thirst, headache, and malaise. Interventions that monitor temperature and aid in lowering body temperature are appropriate. Ineffective airway clearance would be manifested by adventitious breath sounds and difficulty producing secretions. Disorientation and confusion are not noted in this patient and are not typical unless the patient is very hypoxemic. Pleuritic pain is an acute pain that is due to inflammation of the pleura. |
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A patient with pneumonia has a nursing diagnosis of ineffective airway clearance related to pain, fatigue, and thick secretions. An appropriate nursing intervention for the patient is to:
a)encourage a fluid intake of at least 3L/day b)administer oxygen as prescribed to maintain SpO₂ of 95% c)place the patient in semi-Fowler’s position to maximize lung expansion d)teach the patient to take three or four shallow breaths before coughing to minimize pain |
A
Secretions are liquefied and more easily removed by coughing when fluid intake is at least 3L/d. positioning and oxygen administration may help ineffective breathing patterns and impaired oxygen exchange but are not indicated for retained secretions. Deep breaths are necessary to move mucus from distal airways. |
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During an annual health assessment of a 65yo clinic patient, the patient tells the nurse he had the pneumonia vaccine when he was 58. The nurse advises the patient that the best way for him to prevent pneumonia now is to:
a)seek medical care and antibiotic therapy for all upper respiratory infections b)obtain the pneumococcal vaccine this year with an annual influenza vaccine c)obtain the pneumococcal vaccine if he is exposed to individuals with pneumonia d)obtain only the influenza vaccine every year because he has immunity to the pneumococcus |
B
A second dose of the pneumonococcal vaccine should be provided to all persons 65y or older who have not received vaccine within 5 years or were younger than 65y at time of vaccination. Influenza vaccine should be taken each year by those older than 65yo. Antibiotic therapy is not appropriate for all upper respiratory infections unless secondary bacterial infections develop. |
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The resurgence in TB resulting from the emergence of multidrug-resistant strains of Mycobacterium tuberculosis was primarily the result of:
a)a lack of effective means to diagnose TB b)poor compliance with drug therapy in patients with TB c)the increased population of immunosuppressed individuals with AIDS d)indiscriminate use of antitubercular drugs in treatment of other infections |
B
Drug-resistant strains of TB have developed because TB patients’ compliance to drug therapy has been poor and there has been general decreased vigilance in monitoring and follow-up of Tb treatment. Antitubercular drugs are almost exclusively used for Tb infections. TB can be effectively diagnosed with sputum cultures. The incidence of Tb is at epidemic proportions in patients with HIV, but this does not account for drug-resistant strains of TB. |
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A patient diagnosed with class 3TB one week ago is admitted to the hospital with symptoms of chest pain. Initially, the nurse gives the highest priority to:
a)administering the patient’s antitubercular drugs b)admitting the patient to an airborne-infection isolation room c)preparing the patient’s room with suction equipment and extra linens d)placing the patient in an intensive care unit where he can be closely monitored |
B
A patient with class 3TB has clinically active disease, and airborne infection isolation is required for active diseases until the patient has been on drug therapy for at least 2 weeks or until smears are negative on different days. Cardiac monitoring and observation will need to be done with the patient in isolation. The nurse will administer the antitubercular drugs after the patient is in isolation. There should be no need for suction or extra linens after the TB patient is receiving drug therapy. |
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When obtaining a health history from a patient suspected of having early TB, the nurse asks the patient about experiencing:
a)chest pain, hemoptysis, and weight loss b)fatigue, low-grade fever, and night sweats c)cough with purulent mucus and fever with chills d)pleuritic pain, non-productive cough, and temperature elevation at night |
B
TB usually develops insidiously with fatigue, malaise, low-grade fevers, and night sweats. Chest pain and a productive cough may also occur, but hemoptysis is a late symptom. |
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List the components of the four-drug therapy that is recommended for the initial 2-month treatment of clinically active TB:
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INH
Rifadin PZA Myambutol |
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A patient with active TB continues to have positive sputum cultures after 6 months of treatment because she says she cannot remember to take the medication all the time. The best action by the nurse is to:
a)schedule the patient to come to the clinic every day to take the medication b)have a patient who has recovered from TB tell the patient about his successful treatment c)schedule more teaching sessions so the patient will understand the risks of noncompliance d)arrange for directly observed therapy by a responsible family member or a public health nurse |
D
The nurse should notify the public health department if drug compliance is questionable so that follow-up of patients can be made by directly observed treatment (DOT) by a public health nurse or a responsible family member. A patient who cannot remember to take the medication usually will not remember to come to the clinic daily or will find it too inconvenient. Additional teaching, or support from others, is not usually effective for this type of patient. |
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A patient receiving chemotherapy for breast cancer develops a Cryptococcus infection of the lungs and is treated with IV amphotericin B. The nurse monitors the patient carefully during the drug’s administration with the knowledge that this drug increases the patient’s risk for (all that apply):
a)renal impairment b)immunosuppression c)nausea and vomiting d)hypersensitivity reactions e)malignant hyperthermia reaction |
A, C, D
Amphotericin B is a toxic drug with many side effects, including hypersensitivity reactions, fever, chills, malaise, nausea and vomiting, and abnormal renal function, but it does not commonly cause immunosuppression. The side effect that would most commonly intensify when a patient also receives chemotherapeutic agents would be N/V |
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To reduce the risk for most occupational lung diseases, the most important measure promoted by the occupational nurse is:
a)maintaining smoke-free work environments for all employees b)using masks and effective ventilation systems to reduce exposure to irritants c)inspection and monitoring of workplaces by national occupational safety agencies d)requiring periodic chest x-rays and pulmonary function tests for exposed employees |
B
Although all of the precautions identified in this question are appropriate in decreasing the risk of occupational lung diseases, using masks and effective ventilation systems to reduce exposure is the most efficient and affects the greatest number of employees. |
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During a health-promotion program, the nurse plans to target women in a discussion of lung cancer prevention because (all that apply):
a)women develop lung cancer at a younger age than men b)more women die of lung cancer than die from breast cancer c)women have a worse prognosis from lung cancer than do men d)women who smoke are at greater risk to develop lung cancer than men who smoke e)women are more likely to develop small cell carcinoma than men |
A, B, D, E
Smoking by women is taking a great toll, as reflected by the incidence of lung cancer in women. Lung cancer incidence and deaths are decreasing in men, whereas almost all other statistics indicate increased risk in women. The incidence of small cell carcinoma is higher in women than in men. Men still have a worse prognosis than women from lung cancer. |
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A patient with a 40 pack/year history of smoking has recently stopped because of the fear of developing lung cancer. The patient asks the nurse what he can do to learn about whether he develops lung cancer. The best response by the nurse is:
a)“you should get a chest x-ray every 6 months to screen for any new growths” b)“it would be very rare for you to develop lung cancer now that you have stopped smoking” c)“you should monitor for any persistent cough, wheezing, or difficulty breathing, which could indicate tumor growth” d)“screening measures for lung cancer are controversial, but we can discuss the advantages and disadvantages of various measures” |
D
The use of radiography, CT, and sputum cytology has been shown to detect lung cancer at earlier stages but has not decreased lung cancer mortality. There is no recommended screening for lung cancer, if screening is done, the patient be informed of the advantages and disadvantages of each method. A patient who has a smoking history always has an increased risk for lung cancer compared with an individual who has never smoked, but the risk decreases the longer the period of nonsmoking. |
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A patient with a lung mass found on a chest x-ray is undergoing further testing. The nurse explains that a diagnosis of lung cancer can be confirmed by:
a)CT scans b)lung tomograms c)pulmonary angiography d)biopsy positive for malignant cells |
D
Although chest radiographs, lung tomograms, CT scans, MRI, and PET can identify tumours and masses, exact diagnosis of a lung malignancy requires identification of malignant cells either in sputum specimens or biopsies. |
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Collapse of the lung from accumulation of air in the intrapleural space caused by a sucking chest wound is a(n) _____
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Open pneumothorax
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Collapse of the lung from accumulation of blood in the intrapleural space is a(n) _____
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Hemothorax
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Collapse of the lung from accumulation of air in the intrapleural space caused by an injury to the lungs from closed rib fractures is known as a(n) _____
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Closed pneumothorax
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When air in the intrapleural space progressively increases intrathoracic pressure because it cannot escape during expiration, a(n) _____ occurs
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Tension pneumothorax
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Accumulation of lymphatic fluid in the pleural space from a leak in the thoracic duct is known as _____
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Chylothorax
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The usual treatment for large pneumothorax or hemothorax of any cause is a(n) _____ connected to _____
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Chest tube,
Water-seal drainage |
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To determine whether a tension pneumothorax is developing in a patient with chest trauma, the nurse assesses the patient for:
a)dull percussion sounds on the injured side b)severe respiratory distress and tracheal deviation c)muffled and distant heart sounds with decreasing blood pressure d)decreased movement and diminished breath sounds on the affected side |
B
A tension pneumothorax causes many of the same symptoms as a pneumothorax, but severe respiratory distress from collapse of the entire lung with movement of the mediastinal structures and trachea to the unaffected side are present a tension pneumothorax. Percussion dullness on the injured site indicates the presence of blood or fluid, and decreased movement and diminished breath sounds are characteristic of a pneumothorax. Muffled and distant heart sounds indicate a cardiac tamponade. |
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Following a MVA, the nurse assesses the driver for which of the distinctive sign of flail chest?
a)severe hypotension b)chest pain over ribs c)absence of breath sounds d)paradoxical chest movement |
D
Flail chest may occur when two or more ribs are fractured, causing an unstable segment. The chest wall cannot provide the support for ventilation and the injured segment will move paradoxically to the stable portion of the chest (in on expiration; out on inspiration). Absent breath sounds occur following pneumothorax or hemothorax; hypotension occurs with a number of conditions that impair cardiac function; chest pain occurs with a single fractured rib and will be of high priority with flail chest. |
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The nurse should check for leaks in the chest tube and pleural drainage system when:
a)there is a constant bubbling of water in the suction control chamber b)there is a continuous bubbling in the water-seal chamber c)the water levels in the water-seal and suction control chambers are decreased d)fluid in the tubing in the water-seal chamber fluctuates with the patient’s breathing |
B
The water-seal chamber should bubble intermittently as air leaves the lung with exhalation in a spontaneously breathing patient, and continuous bubbling indicates a leak. The water in the suction control chamber will bubble continuously, and the fluid in the tubing in the water-seal chamber fluctuates with the patient’s breathing. Water in the suction control chamber, and perhaps in the water-seal chamber, evaporates and may need to be replaced periodically. |
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When caring for the patient with a chest tube, the nurse should intervene when the nursing assistant is:
a)looping the drainage tubing on the bed b)securing the drainage container in an upright position c)stripping or milking the chest tube to promote drainage d)reminding the patient to cough and deep-breathe every 2 hours |
C
If chest tubes are to be milked or stripped, this procedure should be done only by the professional nurse. This procedure is somewhat controversial because it may dangerously increase pleural pressure, but there is no indication to milk the tubes when there is no bloody drainage, as in a pneumothorax. The nursing assistant can loop the chest tubing on the bed to promote drainage, and patients should be reminded to cough and deep-breathe at least q2h to aid in lung reexpansion. Securing the drainage container in an upright position is also a necessary activity. |
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Following a thoracotomy, the patient has a nursing diagnosis of ineffective airway clearance related to inability to cough as a result of pain and positioning. The best nursing intervention for this patient is to:
a)have the patient drink 16oz of water before attempting to deep-breathe b)ausculate the lungs before and after deep-breathing and coughing regimens c)place the patient in the Trendelenburg position for 30 minutes before the coughing exercises d)medicate the patient with analgesics 20-30minutes before assisting to cough and deep-breathe |
D
A thoracotomy incision is large and involves cutting into bone, muscle, and cartilage, resulting in significant postop pain. The patient has difficulty deep-breathing and coughing because of the pain, and analgesics should be provided before attempting these activities. Water intake is important to liquefy secretions but it is not indicated in this case, nor should a patient with chest trauma or surgery be placed in the Trendelenburg position because it increases intrathoracic pressure. |
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Pleural effusion
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Lung expansion restricted by fluid in the pleural space
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Empyema
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Lung expansion restricted by pus in intrapleural space
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Pleurisy
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Inflammation of the pleura restricting lung movement
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Atelectasis
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Presence of collapsed, airless alveoli
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Idiopathic pulmonary fibrosis
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Excessive connective tissue to lungs
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Kyphoscoliosis
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Spinal augulation restricting ventilation
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Opioid and sedative overdose
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Central depression of respiratory rate and depth
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Muscular dystrophy
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Paralysis of respiratory muscles
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Pickwickian syndrome
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Excess fat restricts chest wall and diaphoragmatic excursion
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Two days after undergoing pelvic surgery, a patient develops marked dyspnea and anxiety. The first action the nurse should take is to:
a)raise the HOB b)notify the health care provider c)take the patient’s pulse and blood pressure d)determine the patient’s SpO₂ with an oximeter |
A
All of the activities are correct, but the first thing to do is raise the HOB to promote respiration in the patient who is dyspenic. The health care provider would not be called until the nurse had assessment date relating to vital signs, pulse oximetry, and any other patient complaints. |
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A pulmonary embolus is suspected in a patient with a DVT who develops hemoptysis, tachycardia, and pleuritic pain, and diagnostic testing is scheduled. The nurse plans to teach the patient about:
a)chest radiographs b)spiral (helical) CT scan c)pulmonary angiography d)ventilation-perfusion lung scan |
B
A spiral (helical) CT is the most frequently test used to diagnose pulmonary emboli because it allows illumination of all anatomic structures and produces a 3-D picture. If a patient cannot have contrast media, a ventilation-perfusion (V/Q) scan is done. Pulmonary angiography is invasive and carries more risk for complications. Chest radiographs do not detect pulmonary emboli until necrosis or abscesses occur. |
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COPD
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Pulmonary capillary/alveolar damage
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Pulmonary fibrosis
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Stiffening of pulmonary vasculature
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Pulmonary embolism
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Obstruction of pulmonary blood flow
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While caring for a patient with primary pulmonary hypertension, the nurse observes that the patient has exertional dyspnea and chest pain, in addition to fatigue. The nurse knows that these symptoms are related to:
a)decreased left ventricular output b)right ventricular hypertrophy and dilation c)increased systemic arterial blood pressure d)development of alveolar interstitial edema |
B
High pressure in the pulmonary arteries increases the workload of the right ventricle and eventually causes right ventricular hypertrophy and dilation, known as cor pulmonade. Eventually, decreased left ventricular output may occur because of decreased return to the left atrium, but it is not the primary effect of pulmonary hypertension. Alveolar interstitial edema is pulmonary edema associated with left ventricular failure. Pulmonary hypertension does not cause systemic hypertension. |
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The primary treatment for cor pulmonade is directed toward:
a)controlling dysrhythmias b)dilating the pulmonary arteries c)strengthening the cardiac muscle d)treating the underlying pulmonary condition |
D
If possible, the primary management of cor pulmonade is treatment of the underlying pulmonary problem that caused the heart problem. Low-flow oxygen therapy will help prevent hypoxemia and hypercapnia, which cause pulmonary vasoconstriction. |
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Six days after a heart-lung transplant, the patient develops a low-grade fever and a decreased SpO₂ with exercise. The nurse recognizes that this may indicate:
a)a normal response to extensive surgery b)a frequently fatal cytomegalovirus infection c)acute rejection that can be treated with corticosteroids d)obliterative bronchiolitis that plugs terminal bronchioles |
C
Acute rejection may occur as early as 5-7d after surgery and is manifested by low-grade fever, fatigue, and oxygen desaturation with exertion. Complete remission of symptoms can be accomplished with bolus corticosteroids. Cytomegalovirus (CMV) and other infections can be fatal but usually occur weeks after surgery and manifest with symptoms of pneumonia. Obliterative bronchiolitis is a late complication of lung transplantation, reflecting chronic rejection. |
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The most important instruction the nurse should provide to a patient to prevent the development of antibiotic-resistant bacterial infection is to:
a)wash the hands after toileting and before eating b)avoid crowds and contact with others with infection c)take prescribed antibiotics at the frequency and for the duration directed d)request antibiotic therapy when a cold or flu does not resolve in 2-3 days |
C
One of the most important factors in the development of antibiotic-resistant strains of organisms has been inappropriate use of antibiotics, and patients and their families should be taught to take full courses of prescribed antibiotics without skipping doses, not to request antibiotics for viral infections, not to take antibiotics prophylactically unless specifically prescribed, and not to take leftover antibiotics. Hand washing and avoiding others with infection are general measures to prevent transmission of infections. |
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The most common method of transmission of HIV infection is:
a)sexual contact with a HIV-infected person b)sharing HIV-contaminated injection equipment c)fetal exposure to infection from HIV-infected mother d)transfusion of HIV-contaminated blood or blood products |
A
Sexual contact is the most common method of HIV transmission. The other methods may transmit the virus but not as frequently. |
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A diagnosis of AIDS can be made in a patient with HIV when there is:
a)CD4⁺T cell count of <500/µl b)WBC count <3000/µl (3x10₉/L) c)development of oral candidiasis (thrush) d)onset of pneumocystis carinii pneumonia |
D
AIDS is diagnosed when an individual with HIV infection meets specific criteria, including development of an opportunistic disease such as pneumocystis carinii pneumonia; a CD4⁺T cell count of <200/ml; or candidiasis of the bronchi, trachea, lungs, or esophagus. Oral candidiasis may occur in intermediate chronic infection and is not a diagnostic criterion for AIDS. WBC count is not a criterion for AIDS diagnosis. |
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An individual with a positive result with the EIA is not considered HIV-antibody positive until confirmed with a repeat positive EIA and positive _____.
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Western blot or IFA
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_____ or _____ are done to confirm repeatedly positive ELISA testing for HIV antibodies.
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Western blot,
Immunofluorescence assay (IFA) |
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The progression of HIV infection is monitored with the use of _____.
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CD4⁺T cell counts or viral load tests
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An individual with HIV infection may have a _____ for 6 months following infection.
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Negative ELISA
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_____ may be done to diagnose HIV infection in infants.
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PCR and viral cultures
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A newborn infant of a mother with HIV infection has a positive HIV antibody test. This indicates that the newborn:
a)has HIV infection b)will require treatment for AIDS c)will most likely develop AIDS within 15 months d)has maternal HIV antibodies but may not have HIV infection |
D
All infants born to HIV-infected mothers will have a positive HIV antibody test because maternal antibodies cross the placental barrier. Within 4 weeks, detection of HIV in infants is possible with testing for the HIV antigen with the use of HIV DNA PCR, HIV RNA PCR, or viral culture. Only 25% of infants born to untreated HIV-infected women are infected with HIV. |
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Differences between normal arterial blood gases and normal mixed venous blood gas values:
a)indicate impaired cardiac output b)indicate that the patient is hemodynamically unstable c)reflect the normal capillary oxygen-carbon dioxide exchange d)occur when the patient has inadequate delivery of oxygen to the tissues |
C
Normal venous blood gas values reflect the normal uptake of oxygen from arterial blood and release of carbon dioxide from cells into the blood, with a decrease in pH due to higher PvCO₂ and also much lower PvO₂ and SvO₂. Mixed venous blood gases are used when patients are hemodynamically unstable to evaluate the amount of oxygen delivered to the tissue and the amount of oxygen consumed by the tissues. |
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If a tracheostomy tube has an inner cannula, it is designed to:
a)allow the patient to speak b)facilitate suctioning of secretions from the tube c)promote cleaning of mucus from the inside of the tube d)increase the volume of air that can be delivered by mechanical ventilation |
C
An inner cannula is a second tubing that fits inside of the outer tracheostomy tube and can be removed and cleaned of mucus that has accumulated on the inside of the tube. Many tracheostomy tubes today do not have inner cannulas because of humidification is adequate, accumulation of mucus should not occur. |
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A patient has chronic bronchitis. To prevent the development of an acute exacerbation of chronic bronchitis (AECB), the nurse teaches the patient to take provided antibiotics with the onset of:
a)rhinitis and headache b)diffuse rhonchi and wheezing c)fever and increased productive cough d)chest pain with a nonproductive cough |
C
Acute bronchitis is the greatest threat to those who have chronic bronchitis, and they often are provided antibiotics to take at the first symptoms, which include fever, increased productive cough, and exertional dyspnea. Diffuse rhonchi and wheezing may be heard on auscultation but would not usually be noted by the patient. Pleuritic pain may also occur, but the cough is productive. |
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An example of a metastatic infection that occurs as a complication of pneumococcal pneumonia is:
a)pleurisy b)empyema c)meningitis d)pleural effusion |
C
Pneumococcal meningitis is a metastatic complication of pneumococcal pneumonia, as well as infectious pericarditis, arthritis, or endocarditis. Pleurisy, empyema, and pleural effusion may also result from pneumococcal pneumonia, but these conditions are caused by local spread rather than a hematogenous route. |
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The class of antibiotics most commonly used to treat a Category 1 CAP is _____.
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Advanced generation macrolides
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The drug of choice for treatment of pneumocystitis carinii pneumonia is _____.
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Trimethoprim/sulfamethoxazole (Bactrim)
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A Group 3 HAP caused by pseudomonas aeruginoas is most likely to be treated with an _____.
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Aminoglycoside
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A patient with MRSA has a Group 3 HAP. Treatment would include the antiobiotic _____.
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Vancomycin
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Group 1 HAPs caused by enteric gram-negative bacilli, such as klebsiella, are treated with a _____.
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Cephalosporin
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The nurse advises a 75yo man that to prevent pneumonia, he should:
a)obtain the pneumococcal vaccine q5/6y b)obtain the pneumococcal vaccine and an annual influenza vaccine c)seek medical care and antibiotic therapy for all upper respiratory infections d)obtain the pneumococcal vaccine if he is exposed to individuals with pneumonia |
B
The pneumococcal vaccine is good for a lifetime except for immunosuppressed patients, who should receive the vaccine q5/6y. The influenza virus undergoes minor changes each year, and the vaccine should be taken by those at risk for influenza and lower respiratory infections annually in the fall before exposure to the flu virus occurs. Antibiotic therapy is not appropriate for all upper respiratory infections unless secondary bacterial infections develop. |
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One of the characteristic pathophysiologic responses to infection by the tubercular bacillus is:
a)metastases of osteocytes from the bone to the lung where they calcify lung tissue b)necrotic abscesses formed from reactions of the TB with lymphocytes c)deposition of antibody-antigen immune complexes in the alveoli of the affected lung d)formation of epithelioid cell granulomas from activation of the cellular immune system |
D
The tubercular bacilli create a cellular immune response with development of an epithelioid granuloma that is surrounded by lymphocytes. The central portion of the granuloma undergoes necrosis characterized by a cheesy appearance and is named caseous necrosis and eventually heals with fibrosis and calcification. |
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A health care provider who has cared for a patient with TB has a 7mm reaction to PPD skin testing. This individual has been _____ TB.
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Infected with
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When a person who is taking corticosteroids for rheumatoid arthritis has a positive PPD skin test, treatment would include drugs for _____ TB infection.
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Latent
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A patient who has HIV and clinical TB should receive combination drug therapy for a minimum of _____ months and _____ beyond culture conversion.
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9,
6 |
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Latent TB infection is treated with _____ therapy.
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INH
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The minimum treatment period for patient with active TB infection is _____ months.
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6
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A diagnosis of TB is established with _____.
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Positive smear and culture
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The nursing assessment of a patient with bronchiectasis is most likely to reveal a history of:
a)chest trauma b)childhood asthma c)smoking or oral tobacco use d)recurrent lower respiratory tract infection |
D
Almost all forms of bronchiectasis are associated with bacterial infections that damage the bronchial walls. The incidence of bronchiectasis has decreased with the use of measles and pertussis vaccines and better treatment of lower respiratory tract infections. |
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In planning care for the patient with bronchiectasis, the nurse includes measure that will:
a)relieve or reduce pain b)prevent paroxysmal coughing c)prevent spread of the disease to others d)promote drainage and removal of mucus |
D
Mucus production is increased in bronchiectasis and collects in the dilated, pouched bronchi. A major goal of treatment is to promote drainage and removal of the mucus, primarily through deep breathing, coughing, and postural drainage. |
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The nurse uses protective measures with patients at risk for lung abscesses based on the knowledge that lung abscesses occur most frequently in patient s with:
a)lung tumors b)altered consciousness c)altered immune response d)pulmonary infarct infections |
B
The most common cause of lung abscesses is aspiration of oropharyngeal materials into the lung, especially when oral and dental hygiene are poor. Positioning to protect the airway and prevent aspiration in patients with altered consciousness is an important measure. |
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During a health-promotion program, the nurse teaches the participants that the best way to prevent lung cancer is to:
a)stop smoking and avoid secondhand smoke b)have an annual cheat x-ray after the age of 50 c)wear masks when exposed to industrial carcinogens d)seek medical care for a cough that persists for more than 2-3 weeks |
A
Smoking is responsible for approximately 80-90% of cases of lung cancer, and enough cannot be said about its contributions to lung cancer as well as many other diseases. To prevent lung cancer, avoid exposure to cigarette smoke. Chest x-rays and evaluation of cough are diagnostic means once cancer has already developed. |
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A patient is diagnosed with cancer of the lung after seeking medical treatment for symptoms of SIADH. The nurse recognizes that the lung malignancy most commonly related to this symptom:
a)can be successfully treated with radiation b)metastasizes early and has the poorest prognosis c)has a good prognosis if surgical resection is possible d)is associated with lung scarring and chronic interstitial fibrosis |
B
SIADH is one manifestation of a paraneoplastic endocrine disturbance associated with small cell lung cancer. Small cell lung cancer is associated with cigarette smoking and has the poorest prognosis because of high malignancy and early spread. Surgical resection of sqamous cell lung cancer and adenocarcinoma is possible if localized, and large cell tumors are somewhat radiosensitive. Adenocarcinoma is associated with lung scarring and chronic interstitial fibrosis. |
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A patient tells the nurse that he uses Echinacea and goldenseal throughout the winter to prevent the flu. The best response by the nurse is:
a)“these products work best when combined with antibiotic therapy” b)“zinc is the best agent to stimulate the immune system and relieve symptoms of flu” c)“both of these products should be used only for a limited time as immunistimulants” d)“they are probably a waste of your money since there is no proof that these agents have any effect on the flu” |
C
Echinacea, goldenseal and zinc have been shown to be effective stimulants of the immune system, and all three may help to reduce the symptoms and duration of the common cold. Echinacea and goldenseal should be taken for limited periods, usually only for the duration of the problem. Antibiotics should not be used for a common cold. |
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The nurse identifies a nursing diagnosis of altered health maintenance related to lack of knowledge of therapeutic regimen for a patient with acute sinusitis who:
a)continues to take antibiotics for a week after symptoms are relieved b)uses aspirin or aspirin-containing products to relieve headache and facial pain c)uses OTC antihistamines to relieve symptoms of congestion and drainage d)reports a lack of improvement in symptoms after 3 days of taking broad-spectrum antibiotics |
C
Classic antihistamines available without a prescription increase mucus viscosity and promote continued symptoms of sinusitis and should be avoided. Antibiotics should be taken for at least 1 week after symptoms are relieved, and aspirin products may be used to relieve sinus pain or fever. Nasal irrigations with a saline solution may also be used. |
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A patient’s wife tells the nurse she thinks her husband has sleep apnea because he snores so loudly. Additional information that the nurse should collect about his obstructive sleep apnea includes the husband’s history of:
a)evening headaches b)sleeping on a soft mattress c)frequent awakening at night d) frequent upper respiratory infections |
C
During apneic periods of sleep, severe hypoxemia and hypercapnia stimulate ventilation and awaken the patient, perhaps as many as 200-400 times a night, resulting in frequent awakening, insomnia, and excessive daytime sleepiness. Morning headaches may also occur. The degree of mattress firmness and a history of upper respiratory infections are not relevant factors. |
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The health care provider prescribes nasal bilevel positive airway pressure (BiPAP) for the patient with sleep apnea. To help the patient tolerate this device, the nurse teaches the patient:
a)to sleep with the HOB elevated b)to use the device only on nights when insomnia occurs c)to use nighttime sedatives to relax the tone of the upper airway d)that although it is uncomfortable, it is very effective in relieving sleep apnea |
D
Compliance is poor with the use of nasal bilevel positive airway pressure device, but it is highly effective, and the patient can eliminate the problems of snoring, personality changes, and cardiovascular complications associated with sleep apnea, encourage its use. The device should be used every night, and nighttime sedatives are contraindicated to prevent relaxation of pharyngeal muscles that contributes to airway closure. HOB elevation is not indicated. |
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The class of antibiotics most commonly used to treat a previously healthy patient with CAP is _____.
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Advanced generation macrolides
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The drug of choice for treatment of pneumocystis jiroveci pneumonia is _____.
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Trimethoprim/sulfamethoxazole (Bactrim)
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The nurse identifies which of the following patients at greatest risk for lung abscess:
a)62yo experiencing seizures following a stroke b)47yo diabetic with an ischemic ulcer on the foot c)67yo recovering from thoracic surgery for lung cancer d)52yo receiving immunosuppressants following a kidney transplant |
A
Patients at risk for lung abscesses are those who cannot protect their airway and are most likely to aspirate material from the GI tract into the lungs. Besides stroke and seizures, risk factors include alcoholism, neuromuscular diseases, drug overdose, and general anesthesia. |
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Thoractomy
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Incision into the thorax
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Lobectomy
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Removal of one lung lobe
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Wedge resection
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Removal of a small lesion
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Segmental resection
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Removal of lung segment
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Lung volume-reduction surgery
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Removal of lung tissue by multiple wedge excisions
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Decortication
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Stripping of a fibrous membrane
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Pneumonectomy
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Removal of a lung
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The health care provider inserts a central catheter for administration of PN and orders the solution to be started when x-ray confirms proper placement of the catheter. Following the x-ray, radiology notifies the nurse that the catheter tip is in the superior vena cava. The most appropriate action by the nurse is to:
a)start the solution at the prescribe introductory rate b)notify the health care provider that the catheter needs readjustment c)continue to infuse the isotonic solution until receiving further orders from the health care provider d)gently push the catheter in 2-3 inches to reposition the tip in the right atrium |
A
Proper placement of the tip of the central catheter for PN is in the superior is or vena cava. If the tip is in the right atrium, the hyperosmolar fluid and the catheter tip may cause erosions of the atrial tissue. Repositioning of the catheter is only done the health care provider or a specially trained nurse. |
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A patient receiving a fat emulsion solution develops nausea, vomiting, and fever. The nurse recognizes that these symptoms may indicate:
a)fat embolism b)a fatty acid deficiency c)a too rapid infusion rate d)an allergic reaction to the solution |
C
Nausea and vomiting and fever occur when lipids are infused quickly. Symptoms of fat emboli include dyspnea, cyanosis, and chest and back pain. Fatty acid deficiency can occur with prolonged PN that does not contain the essential fatty acids. Allergies to fat emulsions do occur but manifest as allergic reactions with urticaria, angioedema, and perhaps anaphylactoid reactions. |
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The physician orders a 10% fat emulsion solution to be administered to a patient who is currently receiving peripheral parenteral nutrition. The most appropriate action by the nurse is to:
a)administer the fat emulsion at the prescribed rate at a new, separate intravenous site b)add the fat emulsion solution to the parenteral nutrition solution since they are compatible c)refrigerate the fat solution until the current bottle of parenteral nutrition has infused and then start the fat emulsion d)connect the tubing of the fat emulsion below the filter on the parenteral nutrition tubing at the injection site closest to the patient |
D
When peripheral parenteral nutrition is being run concurrently with fat emulsions, the fat emulsion should be connected below the filter through a Y-injection site as close as possible to the injection site. A separate IV site is not necessary, but the fat emulsion should be administered through the special tubing provided by the manufacturer. |
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When extubation of the patient is being performed, it is most important to:
a)observe the patient for respiratory distress after tube removal b)have the patient cough to remove secretions before extubation c)perform tracheal suctioning immediately following removal of the tube d)obtain a blood specimen for ABGs immediately after the tube is removed |
A
The nurse should carefully observe the patient for respiratory distress and laryngospasm following extubation that may indicate a need for immediate intubation. The tube and the oropharynx are suctioned before removal of the tube, and the patient is encouraged to cough after the tube is removed. ABGs are not routinely assessed after the tube removal, but SpO₂ may be monitored. |
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Mechanical ventilation is indicated when a patient in respiratory distress has a:
a)PaCO₂ of 50mmHg b)tidal volume of 8ml/kg c)resting minute ventilation of 5L/min d)maximal inspiratory pressure of -15cm H₂O |
D
A maximal inspiratory pressure of -15cm H₂O indicates that the patient does not have enough negative inspiratory force, or muscular strength, to promote effective ventilation and is an indication for mechanical ventilation. Other indications for mechanical ventilation include PaCO₂ greater than 55mmHg, tidal volume less than 5ml/kg, and resting minute ventilation greater than 10L/min. |
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A patient with chronic COPD who is on mechanical assist-control ventilation has PaCO₂ of 40mmHg, PaO₂ of 70mmHg and pH of 7.45. The nurse determines that:
a)the patient is responding optimally to the ventilator settings b)the ventilator setting for rate or volume should be decreased c)PEEP is indicated to increase the PaO₂ and improve gas exchange d)an inverse-ratio ventilation maneuver should be set on the ventilator |
B
The ABGs reflect a trend toward respiratory alkalosis, and although the PaCO₂ is within normal limits, if a patient with COPD is ventilated with a return to normal PaCO₂, the patient will develop an alkalosis because of chronically retained bicarbonate. The patient is being overventilated, and the rate or volume of respirations should be decreased to maintain the PaCO₂ at the patient’s normal value. PEEP is generally contraindicated or used with extreme caution in patients with COPD, and these patients usually do better with a short inspiratory and longer expiratory time. |
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Drug therapy that is indicated for the patient in acute respiratory failure include:
a)sedatives to reduce the work of breathing b)prophylactic antibiotics to prevent respiratory infection c)inhaled corticosteroids to relieve bronchospasm and inflammation d)agents that relieve symptoms and reverse the underlying disease process |
D
Drug therapy indicated for acute respiratory failure depends on the symptoms that are present and the underlying cause of the respiratory failure. Bronchodilators and IV corticosteroids are used if bronchospasm and inflammation are present; antibiotics are used if pulmonary congestion is caused by heart failure; and sedatives may be used if anxiety and agitation increase the degree of hyoxemia. |
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In preparing an alert patient in the ICU for oral endotracheal intubation, the nurse:
a)tells the patient that the tongue should be extruded while the tube is inserted b)explains that the gagging and feelings of suffocation may be experienced during insertion of the tube c)positions the patient supine with the head hanging over the edge of the bed to align the mouth and trachea d)informs the patient that while it will not be possible to talk during insertion of the tube, speech will be possible after it is correctly placed |
B
An alert patient should be informed of the sensations likely to be experienced during endotracheal intubation to help prevent anxiety and panic when feelings of suffocation are experienced. The patient may be asked to extrude the tongue during nasal intubation. The patient is positioned with the mouth, pharynx, and trachea in direct alignment, with the head extended in the ‘sniffing position’, but the head must not be hung over the bed. Speaking is not possible during intubation or while the tube is in place because the tube splits the vocal cords. |
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Indicated for patients at risk for barotraumas
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Pressure ventilator
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Preset volume of gas delivered with pressure-limiting valve
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Volume ventilator
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Inspiration terminated when preset airway pressure achieved
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Pressure ventilator
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Volume of gas delivery limited if obstructions or asynchronous breathing patterns
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Pressure ventilator
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Consistent volume and oxygen concentrations delivered despite lung resistance
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Volume ventilator
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Ventilator delivers gas independent of patient’s ventilator efforts:
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CMV (controlled mechanical ventilation)
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