Med-Surg Sp2017 ARDS & Mechanical Ventilation

Unresponsive arterial hypoxemia

Explanation:

Acute respiratory distress syndrome (ARDS) can be thought of as a spectrum of disease, from its milder form (acute lung injury) to its most severe form of fulminate, life-threatening ARDS. This clinical syndrome is characterized by a severe inflammatory process causing diffuse alveolar damage that results in sudden and progressive pulmonary edema, increasing bilateral infiltrates on chest x-ray, hypoxemia unresponsive to oxygen supplementation regardless of the amount of PEEP, and the absence of an elevated left atrial pressure ( Dushianthan, Grott, Postle, et al., 2011).

The nurse is caring for a patient with suspected ARDS with a pO2 of 53. The patient is placed on oxygen via face mask and the PO2 remains the same. What does the nurse recognize as a key characteristic of ARDS?

Unresponsive arterial hypoxemia

Diminished alveolar dilation

Tachypnea

Increased PaO2

Hypovolemia secondary to leakage of fluid into the interstitial spaces

Explanation:

Systemic hypotension may occur in ARDS as a result of hypovolemia secondary to leakage of fluid into the interstitial spaces and depressed cardiac output from high levels of PEEP therapy. Pulmonary hypertension, not pulmonary hypotension, sometimes is a complication of ARDS, but it is not the cause of the patient becoming hypotensive.

The nurse is caring for a patient in the ICU admitted with ARDS after exposure to toxic fumes from a hazardous spill at work. The patient has become hypotensive. What is the cause of this complication to the ARDS treatment?

Pulmonary hypotension due to decreased cardiac output

Severe and progressive pulmonary hypertension

Hypovolemia secondary to leakage of fluid into the interstitial spaces

Increased cardiac output from high levels of PEEP therapy

Unresponsive arterial hypoxemia.

Explanation:

Clinically, the acute phase of ARDS is marked by a rapid onset of severe dyspnea that usually occurs 12 to 48 hours after the initiating event. A characteristic feature is arterial hypoxemia that does not respond to supplemental oxygen.

A nurse is aware that the diagnostic feature of ARDS is sudden:

Unresponsive arterial hypoxemia.

Diminished alveolar dilation.

Tachypnea

Increased PaO2

Administer oxygen by nasal cannula as ordered.

Explanation:

When a pulmonary embolus places a client at risk for oxygen deprivation, the body compensates by hyperventilating. This causes respiratory alkalosis, as reflected in the client's ABG values. However, the most significant ABG value is the PaO2 value of 60 mm Hg, which indicates hypoxemia. To manage hypoxemia, the nurse should increase oxygenation by administering oxygen via nasal cannula as ordered. Instructing the client to breathe into a paper bag would cause depressed oxygenation when the client reinhaled carbon dioxide. Auscultating breath sounds or encouraging deep breathing and coughing wouldn't improve oxygenation.

A client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH, 7.49; partial pressure of arterial oxygen (PaO2), 60 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 30 mm Hg; bicarbonate (HCO3-) 25 mEq/L. What should the nurse do first?

Instruct the client to breathe into a paper bag.

Administer oxygen by nasal cannula as ordered.

Auscultate breath sounds bilaterally every 4 hours.

Encourage the client to deep-breathe and cough every 2 hours.

A client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH, 7.49; partial pressure of arterial oxygen (PaO2), 60 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 30 mm Hg; bicarbonate (HCO3-) 25 mEq/L. What should the nurse do first?

Instruct the client to breathe into a paper bag.

Administer oxygen by nasal cannula as ordered.

Auscultate breath sounds bilaterally every 4 hours.

Encourage the client to deep-breathe and cough every 2 hours.

pH 7.28

Explanation:

Acute respiratory failure (ARF) is defined as a decrease in the arterial oxygen tension (PaO) to less than 50 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO) to greater than 50 mm Hg (hypercapnia), with an arterial pH of less than 7.35.

Arterial blood gas analysis would reveal which of the following related to acute respiratory failure?

PaO 80 mm Hg

pH 7.28

PaCO 32 mm Hg

pH 7.35

A disease process is present.

Explanation:

This X-ray suggests tuberculosis. An ET tube that's 3/4? above the carina is at an adequate level in the trachea. There's no need to advance it or pull it back.

A nurse is reviewing a client's X-ray. The X-ray shows an endotracheal (ET) tube placed 3/4? (2 cm) above the carina and reveals nodular lesions and patchy infiltrates in the upper lobe. Which interpretation of the X-ray is accurate?

The X-ray is inconclusive.

A disease process is present.

The ET tube must be advanced.

The ET tube must be pulled back.

Brain natriuretic peptide (BNP) level

Explanation:

Common diagnostic tests performed for patients with potential ARDS include plasma brain natriuretic peptide (BNP) levels, echocardiography, and pulmonary artery catheterization. The BNP level is helpful in distinguishing ARDS from cardiogenic pulmonary edema. The carboxyhemoglobin level will be increased in a client with an inhalation injury, which commonly progresses into ARDS. CRP and CBC levels do not help differentiate from a cardiac problem.

The nurse is caring for a patient suspected of having ARDS. What is the most likely diagnostic test ordered in the early stages of this disease to differentiate the patient's symptoms from those of a cardiac etiology?

Carboxyhemoglobin level

Brain natriuretic peptide (BNP) level

C-reactive protein (CRP) level

Complete blood count

Aspiration pneumonia

Explanation:

Low pressure in the cuff can increase the risk for aspiration pneumonia. High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis.

Which of the following is a potential complication of a low pressure in the endotracheal cuff?

Aspiration pneumonia

Tracheal bleeding

Tracheal ischemia

Pressure necrosis

50 and 50

Explanation:

Acute respiratory failure (ARF) is classified as hypoxemic (decrease in arterial oxygen tension [PaO2] to <50 mm Hg on room air) and or hypercapnic (increase in arterial carbon dioxide tension [PaCO2] to >50 mm Hg with an arterial pH of <7.35).

Acute respiratory failure (ARF) occurs when oxygen tension (PaO2) falls to less than __________ mm Hg (hypoxemia) and carbon dioxide tension (PaCO2) rises to greater than __________ mm Hg (hypercapnia).

50 and 50

60 and 60

75 and75

80 and 80

Pleuritic pain

Explanation:

The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain. Pleuritic pain is limited in distribution rather than diffuse; it usually occurs only on one side. The pain may become minimal or absent when the breath is held. It may be localized or radiate to the shoulder or abdomen. Later, as pleural fluid develops, the pain decreases. The scenario does not indicate any trauma to the patient, so a traumatic pneumothorax is implausible. Empyema is unlikely as there is no fever indicative of infection. Myocardial infarction would affect the patient's vital signs profoundly.

The nurse is caring for an 82-year-old patient with a diagnosis of tracheobronchitis. The patient begins complaining of right-sided chest pain that gets worse when he coughs or breathes deeply. Vital signs are within normal limits. What would you suspect this patient is experiencing?

Traumatic pneumothorax

Empyema

Pleuritic pain

Myocardial infarction

Intubate the patient and control breathing with mechanical ventilation

Explanation:

A patient with ARDS may need mechanical ventilation to assist with breathing while the underlying cause of the pulmonary edema can be corrected. The other options are not appropriate.

A patient diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the patient's condition does not improve and the oxygen saturation level continues to decrease what procedure will the nurse expect to assist with in order to assist the patient to breathe easier?

Intubate the patient and control breathing with mechanical ventilation

Increase oxygen administration

Administer a large dose of furosemide (Lasix) IVP stat

Schedule the patient for pulmonary surgery

Ask the client to write, use a picture board, or spell words with an alphabet board.

Explanation:

If the client uses an alternative method of communication, such as writing, using a picture board, or spelling words on an alphabet board, he'll feel more in control and be less frustrated. Assuring the client that everything will be all right offers false reassurance and telling him not to be upset minimizes his feelings. Neither of these methods helps the client to communicate. Family members are also likely to encounter difficulty interpreting the wishes of a client with an endotracheal tube or tracheostomy tube. Making them responsible for interpreting the client's gestures may frustrate them. The client may be weaned off a mechanical ventilator only when the physiologic parameters for weaning have been met.

A client on long-term mechanical ventilation becomes very frustrated when he tries to communicate. Which intervention should the nurse perform to assist the client?

Assure the client that everything will be all right and that he shouldn't become upset.

Ask a family member to interpret what the client is trying to communicate.

Ask the physician to wean the client off the mechanical ventilator to allow the client to talk.

Ask the client to write, use a picture board, or spell words with an alphabet board.

Effective breathing at a rate of 16 breaths/minute through the established airway

Explanation:

Proper suctioning should produce a patent airway, as demonstrated by effective breathing through the airway at a normal respiratory rate of 12 to 20 breaths/minute. The other options suggest ineffective suctioning. A respiratory rate of 28 breaths/minute and accessory muscle use may indicate mild respiratory distress. Increased pulse rate, rapid respirations, and cyanosis are signs of hypoxia. Restlessness, pallor, increased pulse and respiratory rates, and bubbling breath sounds indicate respiratory secretion accumulation.

After suctioning a tracheostomy tube, the nurse assesses the client to determine the effectiveness of the suctioning. Which findings indicate that the airway is now patent?

A respiratory rate of 28 breaths/minute with accessory muscle use

Effective breathing at a rate of 16 breaths/minute through the established airway

Increased pulse rate, rapid respirations, and cyanosis of the skin and nail beds

Restlessness, pallor, increased pulse and respiratory rates, and bubbling breath sounds

keeping his airway patent.

Explanation:

Maintaining a patent airway is the most basic and critical human need. Helping the client communicate, encouraging him to perform ADLs, and preventing him from developing an infection are important to the client's well-being but not as important as having sufficient oxygen to breathe.

A nurse is caring for a client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is:

helping him communicate.

keeping his airway patent.

encouraging him to perform activities of daily living (ADLs).

preventing him from developing an infection.

Baseline arterial blood gas (ABG) levels

Explanation:

Before weaning a patient from mechanical ventilation, it is most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the patient is tolerating the procedure. Other assessment parameters are relevant, but less critical. Measuring fluid volume intake and output is always important when a patient is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the patient's record, and the nurse can refer to them before the weaning process begins.

The acute medical nurse is preparing to wean a patient from the ventilator. Which assessment parameter is most important for the nurse to assess?

Fluid intake for the last 24 hours

Baseline arterial blood gas (ABG) levels

Prior outcomes of weaning

Electrocardiogram (ECG) results

Hypoxia

Explanation:

As the respiratory center in the brain becomes depressed, hypoxia occurs, producing wheezing, bradycardia, and a decreased respiratory rate. Delirium is a state of mental confusion characterized by disorientation to time and place. Hyperventilation (respiratory rate greater than that metabolically necessary for gas exchange) is marked by an increased respiratory rate or tidal volume, or both. Semiconsciousness is a state of impaired consciousness characterized by limited motor and verbal responses and decreased orientation.

A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition?

Hypoxia

Delirium

Hyperventilation

Semiconsciousness

A kink in the ventilator tubing

Explanation:

One reason an alarm on the ventilator, indicating increased peak airway pressure, could sound is from a kink in the ventilator tubing. After making this and other assessments without correction, then it could be a malfunction of the alarm button. Higher than normal endotracheal cuff pressure could cause client tissue damage but would not make the ventilator alarms sound. A cut or slice in the tubing from the ventilator would result in decreased pressure.

A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for

Higher than normal endotracheal cuff pressure

A cut or slice in the tubing from the ventilator

A kink in the ventilator tubing

Malfunction of the alarm button

Measure the patient's oxygen saturation.

Explanation:

The patient's response to suctioning is usually determined by performing chest auscultation and by measuring the patient's oxygen saturation. FET, incentive spirometry, and percussion are not normally used as evaluative techniques.

A nurse has performed tracheal suctioning on a patient who experienced increasing dyspnea prior to a procedure. When applying the nursing process, how can the nurse best evaluate the outcomes of this intervention?

Determine whether the patient can now perform forced expiratory technique (FET).

Percuss the patient's lungs and thorax.

Measure the patient's oxygen saturation.

Have the patient perform incentive spirometry.

10 to 15 seconds

Explanation:

In general, the nurse should apply suction no longer than 10 to 15 seconds because hypoxia and dysrhythmias may develop, leading to cardiac arrest. Applying suction for 30 to 35 seconds is hazardous and may result in the patient's developing hypoxia, which can lead to dysrhythmias and, ultimately, cardiac arrest. Applying suction for 20 to 25 seconds is hazardous and may result in the patient's developing hypoxia, which can lead to dysrhythmias and, ultimately, cardiac arrest. Applying suction for 0 to 5 seconds would provide too little time for effective suctioning of secretions.

When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for which of the following time periods?

0 to 5 seconds

10 to 15 seconds

30 to 35 seconds

20 to 25 seconds

Continues assessing the client's respiratory status frequently

Explanation:

The SIMV setting on a ventilator allows the client to breathe spontaneously with no assistance from the ventilator for those extra breaths. Data in the stem suggest that the ventilator is working correctly. The nurse would continue making frequent respiratory assessments of the client. There are not sufficient data to suggest the client could be removed from the ventilator. There is no reason to increase the ventilator's setting to 14 breaths per minute or to contact respiratory therapy to report the machine is not working properly.

A client is on a positive-pressure ventilator with a synchronized intermittent mandatory ventilation (SIMV) setting. The ventilator is set for 8 breaths per minute. The client is taking 6 breaths per minute independently. The nurse

Consults with the physician about removing the client from the ventilator

Changes the setting on the ventilator to increase breaths to 14 per minute

Continues assessing the client's respiratory status frequently

Contacts the respiratory therapy department to report the ventilator is malfunctioning

acute respiratory distress syndrome (ARDS).

Explanation:

A client who receives massive fluid resuscitation or blood transfusions or who aspirates stomach contents is at highest risk for ARDS, which is associated with catastrophic events, such as multiple trauma, bacteremia, pneumonia, near drowning, and smoke inhalation. COPD refers to a group of chronic diseases, including bronchial asthma, characterized by recurring airflow obstruction in the lungs. Although renal failure may occur in a client with multiple trauma (depending on the organs involved), this client's history points to an assault on the respiratory system secondary to aspiration of stomach contents and massive fluid resuscitation.

A client admitted with multiple traumatic injuries receives massive fluid resuscitation. Later, the physician suspects that the client has aspirated stomach contents. The nurse knows that this client is at highest risk for:

chronic obstructive pulmonary disease (COPD).

bronchial asthma.

acute respiratory distress syndrome (ARDS).

renal failure.

pH 7.25, PaCO2 48, HCO3 24

Explanation:

pH 7.25, PaCO2 48, HCO3 24 = respiratory acidosis pH 7.87, PaCO2 38, HCO3 28 = metabolic alkalosis pH 7.47, PaCO2 28, HCO3 30 = respiratory alkalosis pH 7.49, PaCO2 34, HCO3 25 = respiratory alkalosis

The nurse is interpreting blood gases for a patient with acute respiratory distress syndrome (ARDS). Which set of blood gas values indicates respiratory acidosis?

pH 7.87, PaCO2 38, HCO3 28

pH 7.47, PaCO2 28, HCO3 30

pH 7.49, PaCO2 34, HCO3 25

pH 7.25, PaCO2 48, HCO3 24

Restoration of adequate gas exchange

Explanation:

The objectives of treatment are to correct the underlying cause of respiratory failure and to restore adequate gas exchange in the lung. This is priority over coping and self-care. Long-term ventilation may or may not be indicated.

A patient who involved in a workplace accident suffered a penetrating wound of the chest that led to acute respiratory failure. What goal of treatment should the care team prioritize when planning this patient's care?

Facilitation of long-term intubation

Restoration of adequate gas exchange

Attainment of effective coping

Self-management of oxygen therapy

Hypercapnia, hypoventilation, and hypoxemia

Explanation:

The cardinal physiologic abnormalities of acute respiratory failure are hypercapnia, hypoventilation, and hypoxemia. The nurse should focus on resolving these problems.

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems?

Hypotension, hyperoxemia, and hypercapnia

Hyperventilation, hypertension, and hypocapnia

Hyperoxemia, hypocapnia, and hyperventilation

Hypercapnia, hypoventilation, and hypoxemia

Level of consciousness

Arterial blood gases

Vital signs

Explanation:

Patients are usually treated in the ICU. The nurse assesses the patient's respiratory status by monitoring the level of responsiveness, ABGs, pulse oximetry, and vital signs. Oral intake and coping are not immediate priorities during the acute stage of treatment, but would become more important later during recovery.

A patient is brought to the ED by ambulance after a motor vehicle accident in which the patient received blunt trauma to the chest. The patient is in acute respiratory failure, is intubated, and is transferred to the ICU. What parameters of care should the nurse monitor most closely? Select all that apply.

Coping

Level of consciousness

Oral intake

Arterial blood gases

Vital signs

Acute respiratory failure

Explanation:

Early signs of acute respiratory failure are those associated with impaired oxygenation and may include restlessness, fatigue, headache, dyspnea, air hunger, tachycardia, and increased blood pressure. As the hypoxemia progresses, more obvious signs may be present, including confusion, lethargy, tachycardia, tachypnea, central cyanosis, diaphoresis, and, finally, respiratory arrest. Pneumonia is infectious and would not result from trauma. Pneumoconiosis results from exposure to occupational toxins. A pleural effusion does not cause this constellation of symptoms.

A patient presents to the ED stating she was in a boating accident about 3 hours ago. Now the patient has complaints of headache, fatigue, and the feeling that he "just can't breathe enough." The nurse notes that the patient is restless and tachycardic with an elevated blood pressure. This patient may be in the early stages of what respiratory problem?

Pneumoconiosis

Pleural effusion

Acute respiratory failure

Pneumonia

pH 7.28, PaO2 50 mm Hg

Explanation:

ARF is defined as a decrease in the arterial oxygen tension (PaO2) to less than 50 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to greater than 50 mm Hg (hypercapnia), with an arterial pH of less than 7.35.

A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which of the following results are consistent with this disorder?

pH 7.28, PaO2 50 mm Hg

pH 7.46, PaO2 80 mm Hg

pH 7.36, PaCO2 32 mm Hg

pH 7.35, PaCO2 48 mm Hg

Pneumothorax

Explanation:

Pneumothorax (air in the pleural space) is a potential complication of all central venous access devices. Signs and symptoms include chest pain, dyspnea, shoulder or neck pain, irritability, palpitations, light-headedness, hypotension, cyanosis, and unequal breath sounds. A chest X-ray reveals the collapse of the affected lung that results from pneumothorax. Triple-lumen catheter insertion through the subclavian vein isn't associated with pulmonary embolism, MI, or heart failure.

A client who has just had a triple-lumen catheter placed in his right subclavian vein complains of chest pain and shortness of breath. His blood pressure is decreased from baseline and, on auscultation of his chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect?

Pulmonary embolism

Myocardial infarction (MI)

Heart failure

Pneumothorax

Rapid onset of severe dyspnea

Explanation:

The acute phase of ARDS is marked by a rapid onset of severe dyspnea that usually occurs less than 72 hours after the precipitating event

The nurse is assessing a patient who, following an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which early, most common sign of ARDS?

Rapid onset of severe dyspnea

Inspiratory crackles

Bilateral wheezing

Cyanosis

Sudden onset in client who had normal lung function

Explanation:

Acute respiratory failure occurs suddenly in a client who previously had normal lung function.

The new client on the unit was admitted with acute respiratory failure. What are the signs and symptoms of acute respiratory failure?

Insidious onset in client who had normal lung function

Sudden onset in client who had normal lung function

Insidious onset in client who had compromised lung function

Sudden onset in client who had compromised lung function

Atelectasis

Explanation:

A shallow, monotonous respiratory pattern coupled with immobility places the patient at an increased risk of developing atelectasis. These specific factors are less likely to result in pulmonary embolism or aspiration. ARDS involves an exaggerated inflammatory response and does not normally result from factors such as immobility and shallow breathing.

A perioperative nurse is caring for a postoperative patient. The patient has a shallow respiratory pattern and is reluctant to cough or to begin mobilizing. The nurse should address the patient's increased risk for what complication?

Acute respiratory distress syndrome (ARDS)

Atelectasis

Aspiration

Pulmonary embolism

Partial pressure of arterial oxygen (PaO2)

Explanation:

In acute respiratory failure, administering supplemental oxygen elevates the PaO2. In acute respiratory distress syndrome, elevation of the PaO2 requires positive end-expiratory pressure. In both situations, the PaCO2 is elevated and the pH and HCO3- are depressed.

A client has hypoxemia of pulmonary origin. What portion of arterial blood gas results is most useful in distinguishing between acute respiratory distress syndrome and acute respiratory failure?

Partial pressure of arterial oxygen (PaO2)

Partial pressure of arterial carbon dioxide (PaCO2)

pH

Bicarbonate (HCO3-)

Nutritional support

Explanation:

Aggressive, supportive care must be provided to compensate for the severe respiratory dysfunction. This supportive therapy almost always includes intubation and mechanical ventilation. In addition, circulatory support, adequate fluid volume, and nutritional support are important. Oral intake is contraindicated by intubation. Counseling and occupational therapy would not be priorities during the acute stage of ARDS.

A firefighter was trapped in a fire and is admitted to the ICU for smoke inhalation. After 12 hours, the firefighter is exhibiting signs of ARDS and is intubated. What other supportive measures are initiated in a patient with ARDS?

Psychological counseling

Nutritional support

High-protein oral diet

Occupational therapy

Normal lung function

Explanation:

Acute respiratory failure occurs suddenly in clients who previously had normal lung function.

The nurse identifies which finding to be most consistent prior to the onset of acute respiratory distress?

Normal lung function

Loss of lung function

Chronic lung disease

Slow onset of symptoms

Decreases hypoxemia

Decreases patient anxiety

Sustains positive end expiratory pressure (PEEP)

Explanation:

An in-line suction device allows the patient to be suctioned without being disconnected from the ventilator circuit. In-line suctioning (also called closed suctioning) decreases hypoxemia, sustains PEEP, and can decrease patient anxiety associated with suctioning (Sole et al., 2013).

The nurse is using an in-line suction kit to suction a patient who is intubated and on a mechanical ventilator. What benefits does inline suction have for the patient? (Select all that apply.)

Decreases hypoxemia

Decreases patient anxiety

Sustains positive end expiratory pressure (PEEP)

Increases oxygen consumption

Prevents aspiration

Negative-pressure ventilator

Explanation:

This client needs ventilatory support. His PaO2 is low despite receiving a high dose of oxygen. The iron lung or drinker respiratory tank is an example of a negative-pressure ventilator. This type of ventilator is used mainly with chronic respiratory failure associated with neurological disorders, such as muscular dystrophy. It does not require intubation of the client. The most common ventilator is the positive-pressure ventilator, but this involves intubation with an endotracheal tube or tracheostomy. CPAP is used for obstructive sleep apnea. Bi-PAP is used for those with severe COPD or sleep apnea who require ventilatory assistance at night.

A young male client has muscular dystrophy. His PaO2 is 42 mm Hg with a FiO2 of 80%. Which of the following treatments would be least invasive and most appropriate for this client?

Negative-pressure ventilator

Positive-pressure ventilator

Continuous positive airway pressure (CPAP)

Bilevel positive airway pressure (Bi-PAP)

Tracheal ischemia

Tracheal bleeding

Pressure necrosis

Explanation:

Complications can occur from pressure exerted by the cuff on the tracheal wall. Cuff pressures should be maintained between 15 and 20 mm Hg (Morton, Fontaine, Hudak, et al., 2009). High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis, whereas low cuff pressure can increase the risk of aspiration pneumonia. Routine deflation of the cuff is not recommended because of the increased risk of aspiration and hypoxia.

A patient is being mechanically ventilated with an oral endotracheal tube in place. The nurse observes that the cuff pressure is 25 mm Hg. The nurse is aware of what complications that can be caused by this pressure? (Select all that apply.)

Tracheal aspiration

Hypoxia

Tracheal ischemia

Tracheal bleeding

Pressure necrosis

Gastrointestinal hemorrhage

Explanation:

Gastrointestinal hemorrhage occurs in approximately 25% of clients receiving prolonged mechanical ventilation. Other possible complications include incorrect ventilation, oxygen toxicity, fluid imbalance, decreased cardiac output, pneumothorax, infection, and atelectasis. Immunosuppression and pulmonary emboli are not direct consequences of mechanical ventilation.

The nurse should monitor a client receiving mechanical ventilation for which of the following complications?

Gastrointestinal hemorrhage

Immunosuppression

Increased cardiac output

Pulmonary emboli

Vital capacity of 13 mL/kg

Tidal volume of 8.5 mL/kg

PaO2 of 64 mm Hg

Explanation:

Weaning criteria for clients are as follows: Vital capacity 10 to 15 mL/kg; Maximum inspiratory pressure at least -20 cm H2; Tidal volume: 7 to 9 mL/kg; Minute ventilation: 6 L/min; Rapid/shallow breathing index below 100 breaths/min; PaO2 > 60 mm Hg; FiO2 < 40%

Which of the following are indicators that a client is ready to be weaned from a ventilator? Select all that apply.

Vital capacity of 13 mL/kg

Tidal volume of 8.5 mL/kg

Rapid/shallow breathing index of 112 breaths/min

PaO2 of 64 mm Hg

FiO2 45%

Assist control

Explanation:

Assist-control ventilation provides full ventilator support by delivering a preset tidal volume and respiratory rate. IMV provides a combination of mechanically assisted breaths and spontaneous breaths. SIMV delivers a preset tidal volume and number of breaths per minute. Between ventilator-delivered breaths, the patient can breathe spontaneously with no assistance from the ventilator for those extra breaths.

Which of the following ventilator modes provides full ventilatory support by delivering a present tidal volume and respiratory rate?

IMV

SIMV

Assist control

Pressure support

Cleaning the patient's mouth with chlorhexidine daily

Explanation:

The five key elements of the VAP bundle include the following: elevation of the head of the bed (30 to 45 degrees: semi-Fowler's position), daily "sedation vacations," and assessment of readiness to extubate (see below); peptic ulcer disease prophylaxis (with histamine-2 receptor antagonists, such as ranitidine [Zantac]); deep venous thrombosis (DVT) prophylaxis; and daily oral care with chlorhexidine (0.12% oral rinses). The patient should be turned and repositioned every 2 hours to prevent complications of immobility and atelectasis and to optimize lung expansion.

The nurse is caring for a patient in the ICU who is receiving mechanical ventilation. Which of the following nursing measures are implemented in an effort to reduce the patient's risk of developing ventilator-associated pneumonia (VAP)?

Cleaning the patient's mouth with chlorhexidine daily

Maintaining the patient in a high Fowler's position

Ensuring that the patient remains sedated while intubated

Turning and repositioning the patient every 4 hours

20 minutes

Explanation:

ABGs should be obtained to measure carbon dioxide partial pressure (PaCO), pH, and PaO after 20 minutes of continuous mechanical ventilation.

Arterial blood gases should be obtained at which timeframe following the initiation of continuous mechanical ventilation?

10 minutes

15 minutes

20 minutes

25 minutes

Disconnect the patient from the ventilator and manually ventilate the patient with a manual resuscitation bag until the problem is resolved.

Explanation:

If the cause of an alarm cannot be determined, the nurse should disconnect the patient from the ventilator and manually ventilate the patient, because leaving the patient on the mechanical ventilator may be dangerous.

The nurse hears the patient's ventilator alarm sound and attempts to find the cause. What is the priority action of the nurse when the cause of the alarm is not able to be determined?

Call respiratory therapy and wait until they arrive to determine what is happening.

Disconnect the patient from the ventilator and manually ventilate the patient with a manual resuscitation bag until the problem is resolved.

Stop the ventilator by pressing the off button, wait 15 seconds, and then turn it on again to see if the alarm stops.

Suction the patient since the patient may be obstructed by secretions.

Increase in compliance

Explanation:

A decrease in pressure in the mechanical ventilator may be caused by an increase in compliance. Kinked tubing and decreasing lung compliance, and a plugged airway tube cause an increase in peak airway pressure.

Which of the following would indicate a decrease in pressure with mechanical ventilation?

Kinked tubing

Increase in compliance

Decrease in lung compliance

Plugged airway tube

Assess the patient's lung sounds and SAO2 via pulse oximeter.

Explanation:

Assessment data indicate the need for suctioning and allow the nurse to monitor the effect of suction on the patient's level of oxygenation. Explaining the procedure would be the second step; performing hand hygiene is the third step, and turning on the suction source is the fourth step.

The nurse is preparing to suction a patient with an endotracheal tube. What should be the nurse's first step in the suctioning process?

Explain the suctioning procedure to the patient and reposition the patient.

Turn on suction source at a pressure not exceeding 120 mm Hg.

Assess the patient's lung sounds and SAO2 via pulse oximeter.

Perform hand hygiene and don nonsterile gloves, goggles, gown, and mask.

The patient will have an insertion of a tracheostomy tube.

Explanation:

Endotracheal intubation may be used for no longer than 14 to 21 days, by which time a tracheostomy must be considered to decrease irritation of and trauma to the tracheal lining, to reduce the incidence of vocal cord paralysis (secondary to laryngeal nerve damage), and to decrease the work of breathing (Wiegand, 2011).

A patient in the ICU has been orally intubated and on mechanical ventilation for 2 weeks after having a severe stroke. What action does the nurse anticipate the physician will take now that the patient has been intubated for this length of time?

The patient will be extubated and another endotracheal tube will be inserted.

The patient will be extubated and a nasotracheal tube will be inserted.

The patient will have an insertion of a tracheostomy tube.

The patient will begin the weaning process.

They help prevent cardiac arrhythmias.

Explanation:

ET suctioning removes oxygen, lowering the partial pressure of arterial oxygen; this, in turn, may induce a cardiac arrhythmia. Hyperventilating and hyperoxygenating the client before and during (or after) suctioning helps prevent this complication. Subcutaneous emphysema occurs when air from the pleural cavity leaks into subcutaneous tissue; it isn't a complication associated with suctioning. Hyperventilation and hyperoxygenation can't prevent a pneumothorax because this condition itself indicates air in the pleural space. Pulmonary edema is associated with cardiac dysfunction, not ET suctioning.

A client in acute respiratory distress is brought to the emergency department. After endotracheal (ET) intubation and initiation of mechanical ventilation, the client is transferred to the intensive care unit. Before suctioning the ET tube, the nurse hyperventilates and hyperoxygenates the client. What is the rationale for these interventions?

They help prevent subcutaneous emphysema.

They help prevent pneumothorax.

They help prevent cardiac arrhythmias.

They help prevent pulmonary edema.

Reduced cardiac output

Explanation:

PEEP reduces cardiac output by increasing intrathoracic pressure and reducing the amount of blood delivered to the left side of the heart. It doesn't affect heart rate, but a decrease in cardiac output may reduce blood pressure, commonly causing compensatory tachycardia, not bradycardia. However, the resulting tachycardia isn't a direct effect of PEEP therapy itself.

Positive end-expiratory pressure (PEEP) therapy has which effect on the heart?

Bradycardia

Tachycardia

Increased blood pressure

Reduced cardiac output

Wait several minutes and then repeat suctioning.

Explanation:

If additional suctioning is needed, the nurse should withdraw the catheter to the back of the pharynx, reassure the patient, and oxygenate for several minutes before resuming suctioning. Chest physiotherapy and postural drainage are not necessarily indicated.

The nurse is performing nasotracheal suctioning on a medical patient and obtains copious amounts of secretions from the patient's airway, even after inserting and withdrawing the catheter several times. How should the nurse proceed?

Continue suctioning the patient until no more secretions are obtained.

Perform chest physiotherapy rather than nasotracheal suctioning.

Wait several minutes and then repeat suctioning.

Perform postural drainage and then repeat suctioning.

When adventitious breath sounds are auscultated

Explanation:

It is usually necessary to suction the patient's secretions because of the decreased effectiveness of the cough mechanism. Tracheal suctioning is performed when adventitious breath sounds are detected or whenever secretions are present. Unnecessary suctioning, such as scheduling every 2 hours, can initiate bronchospasm and cause trauma to the tracheal mucosa.

While caring for a patient with an endotracheal tube, the nurses recognizes that suctioning is required how often?

Every 2 hours when the patient is awake

When adventitious breath sounds are auscultated

When there is a need to prevent the patient from coughing

When the nurse needs to stimulate the cough reflex

"When an endotracheal tube is left in too long it can damage the lining of the windpipe."

Explanation:

Endotracheal intubation may be used for no longer than 2 to 3 weeks, by which time a tracheostomy must be considered to decrease irritation of and, trauma to, the tracheal lining, to reduce the incidence of vocal cord paralysis (secondary to laryngeal nerve damage), and to decrease the work of breathing. The need for long-term ventilation would not be the primary rationale for this change in treatment. Endotracheal tubes do not diminish the breathing reflex.

Reference:

A patient in the ICU has had an endotracheal tube in place for 3 weeks. The physician has ordered that a tracheostomy tube be placed. The patient's family wants to know why the endotracheal tube cannot be left in place. What would be the nurse's best response?

"The physician may feel that mechanical ventilation will have to be used long-term."

"Long-term use of an endotracheal tube diminishes the normal breathing reflex."

"When an endotracheal tube is left in too long it can damage the lining of the windpipe."

"It is much harder to breathe through an endotracheal tube than a tracheostomy."

Impaired gas exchange related to ventilator setting adjustments

Explanation:

All the nursing diagnoses are appropriate for this client. Per Maslow's hierarchy of needs, airway, breathing, and circulation are the highest priorities within physiological needs. The client has an oxygen saturation of 91%, which is below normal. This places impaired gas exchange as the highest prioritized nursing diagnosis.

A nurse is attempting to wean a client after 2 days on the mechanical ventilator. The client has an endotracheal tube present with the cuff inflated to 15 mm Hg. The nurse has suctioned the client with return of small amounts of thin white mucus. Lung sounds are clear. Oxygen saturation levels are 91%. What is the priority nursing diagnosis for this client?

Impaired gas exchange related to ventilator setting adjustments

Risk for trauma related to endotracheal intubation and cuff pressure

Risk for infection related to endotracheal intubation and suctioning

Impaired physical mobility related to being on a ventilator

synchronized intermittent mandatory ventilation (SIMV).

Explanation:

In SIMV mode, the ventilator delivers a preset number of breaths at a preset tidal volume. The client can breathe on his own in between the breaths delivered by the ventilator. In PSV, a pressure plateau is added to the ventilator to prevent the airway pressure from falling beneath a preset level. In AC ventilation, the ventilator delivers a preset number of breaths at a preset tidal volume and any breaths that the client takes on his own are assisted by the ventilator so they reach the preset tidal volume. In CPAP, the ventilator provides only positive airway pressure; it doesn't provide any breaths to the client.

A nurse is caring for a client who was intubated because of respiratory failure. The client is now receiving mechanical ventilation with a preset tidal volume and number of breaths each minute. The client has the ability to breathe spontaneously between the ventilator breaths with no ventilator assistance. The nurse should document the ventilator setting as:

pressure support ventilation (PSV).

synchronized intermittent mandatory ventilation (SIMV).

assist-control (AC) ventilation.

continuous positive airway pressure (CPAP).

Continuous positive airway pressure

Explanation:

Continuous positive airway pressure (CPAP) provides positive pressure to the airways throughout the respiratory cycle. Although it can be used as an adjunct to mechanical ventilation with a cuffed endotracheal tube or tracheostomy tube to open the alveoli, it is also used with a leak-proof mask to keep alveoli open, thereby preventing respiratory failure. CPAP is the most effective treatment for obstructive sleep apnea because the positive pressure acts as a splint, keeping the upper airway and trachea open during sleep. To use CPAP, the patient must be breathing independently.

A patient is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this patient?

Surgery to remove the tonsils and adenoids

Medications to assist the patient with sleep at night

Continuous positive airway pressure

Bi-level positive airway pressure

Stable vital signs and ABGs

Explanation:

Among many other predictors, stable vital signs and ABGs are important predictors of successful weaning. Pulse oximetry must greatly exceed 80%. Nutritional status is important, but vital signs and ABGs are even more significant. Patients who are weaned may or may not have full level of consciousness.

The critical care nurse and the other members of the care team are assessing the patient to see if he is ready to be weaned from the ventilator. What are the most important predictors of successful weaning that the nurse should identify?

Stable vital signs and ABGs

Pulse oximetry above 80% and stable vital signs

Stable nutritional status and ABGs

Normal orientation and level of consciousness

Auscultate the lung for adventitious sounds.

Explanation:

When a tracheostomy or endotracheal tube is in place, it is usually necessary to suction the patient's secretions because of the decreased effectiveness of the cough mechanism. Tracheal suctioning is performed when adventitious breath sounds are detected or whenever secretions are obviously present. Unnecessary suctioning can initiate bronchospasm and cause mechanical trauma to the tracheal mucosa.

A new ICU nurse is observed by her preceptor entering a patient's room to suction the tracheostomy after performing the task 15 minutes before. What should the preceptor educate the new nurse to do to ensure that the patient needs to be suctioned?

Auscultate the lung for adventitious sounds.

Have the patient inform the nurse of the need to be suctioned.

Assess the CO2 level to determine if the patient requires suctioning.

Have the patient cough.

A patient requires permanent ventilation.

Explanation:

A tracheostomy permits long-term use of mechanical ventilation to prevent aspiration of oral and gastric secretions in the unconscious or paralyzed patient. Indications for a tracheostomy do not include a respiratory rate of 10 breaths per minute, symptoms of dyspnea, or respiratory acidosis.

What would the critical care nurse recognize as a condition that may indicate a patient's need to have a tracheostomy?

A patient has a respiratory rate of 10 breaths per minute.

A patient requires permanent ventilation.

A patient exhibits symptoms of dyspnea.

A patient has respiratory acidosis.

Runs of ventricular tachycardia

Explanation:

Ventricular tachycardia indicates that the client isn't tolerating the weaning process. The weaning process should be stopped before lethal ventricular arrhythmias occur. A respiratory rate of 16 breaths/minute and an oxygen saturation of 93% are normal findings. Although the client's blood pressure has increased, it hasn't increased more than 20% over baseline, which would indicate that the client isn't tolerating the weaning process.

A nurse is weaning a client from mechanical ventilation. Which assessment finding indicates the weaning process should be stopped?

Respiratory rate of 16 breaths/minute

Oxygen saturation of 93%

Runs of ventricular tachycardia

Blood pressure increase from 120/74 mm Hg to 134/80 mm Hg

Aspiration pneumonia

Explanation:

Low pressure in the cuff can increase the risk for aspiration pneumonia. High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis.

Which of the following is a potential complication of a low pressure in the ET cuff?

Tracheal bleeding

Aspiration pneumonia

Tracheal ischemia

Pressure necrosis

Volume cycled

Explanation:

With volume-cycled ventilation, the volume of air to be delivered with each inspiration is present. Negative pressure ventilators exert a negative pressure on the external chest. Time-cycled ventilators terminate or control inspiration after a preset time. When the pressure-cycled ventilator cycles on, it delivers a flow of air (inspiration) until it reaches a present pressure, and then cycles off, and expiration occurs passively.

Which type of ventilator has a pre-sent volume of air to be delivered with each inspiration?

Negative pressure

Volume cycled

Time cycled

Pressure cycled