Question 1

The nurse monitoring a client with adult respiratory distress syndrome (ARDS) would closely assess for

Accepted Answer

The hallmark of ARDS is increased permeability of the pulmonary endothelium and alveolar epithelium, with resultant movement of fluid into the interstitial and alveolar spaces. This leads to the development of pulmonary edema, which decreases lung compliance and impairs oxygen transport.

Question 2

As part of the immediate care plan for a client with pulmonary edema and a nursing diagnosis of Impaired Gas Exchange, the nurse would

Accepted Answer

The nurse should monitor vital signs every 15 minutes initially until the client is stable and administer oxygen as ordered using a high-flow rebreather bag to maintain oxygenation (oxygen saturation above 90%). Mechanical ventilation and intubation equipment should be nearby. To reduce preload, the client should be positioned with the legs dependent. Raising edematous legs increases venous return and will stress the overtaxed left ventricle.

Question 3

A client who underwent surgery is intubated and receiving mechanical ventilation. The client is receiving a neuromuscular blocking agent to stop spontaneous breathing that is not in synchrony with the ventilator. The appropriate approach by the nurse to the client's postoperative pain control would be

Accepted Answer

Because the neuromuscular blocking agent does not inhibit pain or awareness, it is combined with a sedative or an anti-anxiety agent (anxiolytic). Pain medication may also be required if the client has pain.

Question 4

A client who sustained a head injury is intubated and receiving volume-cycled mechanical ventilation via the controlled mechanical ventilation (CMV) mode. The nurse would explain that this means

Accepted Answer

In the CMV mode the volume-cycled ventilator delivers a preset tidal volume. No allowance is made for spontaneous breaths. Because the ventilator is not responsive to the client's efforts, the CMV mode can lead to agitation and asynchrony.

Question 5

A client is being transported to the ED after sustaining carbon monoxide (CO) poisoning in a house fire. The nurse would prepare to administer

Accepted Answer

CO poisoning is treated by inhalation of 100% oxygen to shorten the half-life of CO to about an hour. Hyperbaric oxygen may be required to reduce the half-life of CO to minutes by forcing it off of the hemoglobin molecule.

Question 6

When a client is admitted to the ED with a sucking chest wound, the nurse initially would

Accepted Answer

When an open sucking chest wound is detected, emergency intervention includes immediately covering the wound securely with anything available. The nurse should not waste time looking for a sterile gauze petroleum dressing if it is not immediately available.

Question 7

A client who was extubated 2 hours ago is becoming increasingly restless. The last vital signs before extubation were pulse 88 beats/min, respirations 18 breaths/min, blood pressure (138/78)mm Hg, and PaCO₂ 45 mm Hg. Current vital signs include pulse 104 beats/min, respirations 26 breaths/min, blood pressure (140/80) mm Hg, and PaCO₂ 62 mm Hg. The nurse would

Accepted Answer

The nurse should assess the client for indications of respiratory distress and hypoxemia, as evidenced by restlessness, irritability, tachycardia, tachypnea, and decreased PaO₂ or increased PaCO₂. If these manifestations are noted, the nurse should notify the physician and prepare for reintubation.

Question 8

The nurse would explain that the use of positive end-expiratory pressure (PEEP) assists the client on mechanical ventilation by

Accepted Answer

PEEP keeps the alveoli open to offer more ventilation surface by using pressures of 5 to 20 cm H₂O.

Question 9

When a client is admitted to the ED with tension pneumothorax and mediastinal shift following an automobile accident, the nurse would know that the client would exhibit

Accepted Answer

Mediastinal shift may cause (a) compression of the lung in the direction of the shift and (b) compression, traction, torsion, or kinking of the great vessels; thus blood return to the heart is dangerously impaired. The latter causes a subsequent decrease in cardiac output and blood pressure.

Question 10

When the ED nurse receives a radio call from an ambulance transporting a client who sustained chest trauma and has a severe flail chest, the nurse would set up the treatment area with

Accepted Answer

Treatment is usually with intubation and mechanical ventilation, which can (a) restore adequate ventilation, thus reducing hypoxia and hypercapnea; (b) decrease paradoxical motion by using positive pressure to stabilize the chest wall internally; (c) relieve pain by decreasing movement of the fractured ribs; and (d) provide an avenue for removal of secretions.

Question 11

In the nursing care of a client recently intubated and placed on mechanical ventilation, the nursing action that would take highest priority is

Accepted Answer

The lowered cardiac output will be reflected in the hypotension that clients typically exhibit immediately after being placed on mechanical ventilation. It is imperative that blood pressure be monitored closely.

Question 12

The nurse would explain that emergency treatment of a tension pneumothorax requires

Accepted Answer

The immediate intervention is to convert tension pneumothorax into open pneumothorax (a less serious disorder). If a delay is anticipated (with chest tube insertion), a 14- to 18-gauge needle is inserted into the pleural space of the affected side at the level of the second intercostal space at the midclavicular line.

Question 13

The nurse would determine that a client with fractured ribs needs further self-care instructions when the client says

Accepted Answer

Fractured ribs are generally treated conservatively with rest, local heat, and analgesics. Strapping the ribs is no longer recommended because it restricts deep breathing and can increase the incidence of atelectasis and pneumonia.

Question 14

When a client developed a hemothorax, the physician inserted a chest catheter connected to a drainage system. In the first 2 hours, 900 ml of blood drainage was collected. The nurse would

Accepted Answer

Large amounts of drainage (200 ml/hr or more) should be reported the physician immediately.

Question 15

A client admitted to the emergency department (ED) with severe chest injuries and significant hypovolemia caused by hemorrhage would be transfused to replace blood loss initially with

Accepted Answer

A chest-injured client may require large quantities of blood replacement. Until the results of typing and crossmatching are available, the client is given O-negative blood.

Question 16

A client with respiratory failure was intubated with an oral endotracheal (ET) tube 2 hours ago. Suspecting that the tube has changed position slightly since insertion, the nurse would assess the

Accepted Answer

The nurse records in the nursing notes and on the respiratory flow sheet the point at which the ET tube meets the lips or nostrils by using the numbers listed on the tube's side. If the tube slips, its correct position can be quickly established. Then the nurse should listen to lung sounds.

Question 17

Once a near-drowning victim is stabilized, the nurse would continue to assess the client for

Accepted Answer

Clients are at high risk for pulmonary edema even several hours after a near-drowning incident.

Question 18

The nurse would determine that a client is having a dysfunctional ventilatory weaning response if the client's respiratory rate rises to

Accepted Answer

Manifestations of respiratory muscle fatigue include a respiratory rate of more than 30 breaths per minute or higher, increased PaCO₂, abnormal patterns of breathing, hemodynamic changes (e.g., dysrhythmias), diaphoresis, anxiety, and dyspnea.

Question 19

When a client with a cuffed ET tube reports shortness of breath, the nurse would

Accepted Answer

If the client can talk, the cuff is not inflated. The complaint of shortness of breath is also related to the ET tube not being tightly fitted.

Question 20

After dressing a sucking chest wound, the nurse notes that the client is developing severe dyspnea, tachypnea, cyanosis, tachycardia, and asymmetrical chest movements. The nurse would

Accepted Answer

If a tension pneumothorax appears to be developing after the wound is sealed, the nurse should immediately unplug the seal to allow the air to escape.

Quiz 63: Management of Clients with Acute Pulmonary Disorders