PCCN Review - Pulmonary

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PCCN review questions as given by the AACN

Your patient had an exacerbation of COPD. The rapid response team was called and is currently intubating the patient and preparing him for transfer to ICU. When the family visits, they are shocked to see the people working with the patient. No one had told them the patient had deteriorated and required intubation. After the patient is intubated and is being wheeled past them, family members try to communicate verbally with the patient, but he does not respond except to gesture. The nurse should tell the family members:

-They must leave the area because they are exciting the patient.
-The tube used for breathing prevents the patient from speaking
-They must speak with the doctor, who will explain why the patient cannot speak
-The patient is very ill and may die.

The tube used for breathing prevents the patient from speaking

This is a case where communication is clearly the problem. The family should have been informed by someone that the patient needed assistance with breathing and that they should expect a transfer. It should also have been mentioned how the patient might look in the ICU. In addition, it could have been communicated about the patient's inability to speak.

The other answers are all non-theraputic responses. The family is clearly distressed, so a simple explaination in best.

Ben was just transferred to the PCU. He had been in ICU for 2 weeks. Ben was intubated for a time because of his ARDs. On arrival to your unit, you note that he is tachycardic and restless. Ben states, "I can't be here now. What if something like this happens to me again?" The nurse's best response would be:

-The nurses in our unit can take care of you
-We are not very far away at the nurses' station
-Your insurance will not cover another day there
-You sound concerned about leaving the ICU

You sound concerned about leaving the ICU

Theraputic communication occurs when the patient's feelings are validated. This response allows for the patient to express the concerns he has about the transfer. The other answers are closed and judgmental and do not allow for any expression of feeling from the patient.

Ben was just transferred to the PCU. He had been in ICU for 2 weeks. Ben was intubated for a time because of his ARDs. On arrival to your unit, you note that he is tachycardic and restless. A set of blood gases drawn just prior to his transfer show:

pH 7.52, PaCO2 31, HCO3 22, PaO2 87.

These results would indicate:

-Respiratory acidosis
-Respiratory alkalosis
-Metabloic acidosis
-Metabolic alkalosis

Respiratory alkalosis

Ben was quite anxious and tachycardic. His RR probably was increased because of both anxiety and his condition.
He would blow off CO2.
His pH is below normal, so it is uncompensated.
The HCO3 is low, indicating alkalosis

The interpretation would be:
Uncompensated Respiratory Alkolosis

Ben was just transferred to the PCU. He had been in ICU for 2 weeks. Ben was intubated for a time because of his ARDs. On arrival to your unit, you note that he is tachycardic and restless. Ben is finally released from the hospital. He plans to visit his family in Denver. Part of the patient teaching for Ben should include information on the effects of high altitude on his ability to oxygenate effectively. Which of the following changes would be expected on his blood gas results?

-The pH would decrease
-No effect
-The O2 saturation would decrease
-The PaO2 would increase

The O2 saturation would decrease

At higher altitudes, there is decreased atmospheric pressure to force oxygen into the lungs. To compensate for the lower pressure, the person must breathe faster. The percentage of oxygen remains the same, but the partial pressure of the oxygen decreases. Aterial PaO2 decreases, as does O2 saturation. The rapid breathing will result in hyperventillation, raising the pH and lowering the PaCO2 level.

SaO2 values account for what % of O2 carreid within the bloodstream?

-2-3%
-10-24%
-97-98%
-100%

97-98%

The % of total oxygen carried within the bloodstream attributed to the SaO2 is 97-98%.
SaO2 is the arterial saturation of hemoglobin. The % corresponds to the % of hemoglobin on the red blood cells that carries O2. Typically this % is documented as normal when within 93-99%.
PaO2 is the % of O2 within the bloodstream that is free or dissolved in the plasma. This value is documented in mmHg and is considered normal when within the range of 80-100 mmHg.

Hypoxemia is best defined as:

-A decrease in O2 at the cellular level
-A decrease in O2 levels in arterial blood
-A decrease in O2 levels in venous blood
-A decrease in O2 levels from the brain

A decrease in O2 levels in arterial blood

Hypoxemia is a decrease in O2 levels in arterial blood or PaO2 < 80 mmHg.
Hypoxia is defined as a decreased oxygen level at the cellular level.
Decreased O2 levels within veins refer to PaO2 < 50mmHg
Decreased O2 levels within the brain refer to ScVO2 < 20

Your patient has been diagnosed with pulmonary HTN. Which of the following compensatory mechanisms would be expected if the patient suffered from chronic hypoxia?

-Polycythemia
-Hypoplasia of the pulmonary vasculature
-Thinning of blood vessels in the lungs
-Cor pulmonale

Polycythemia

Effects of acute hypoxia are reversible.
Chronic hypoxia causes permanent changes in the lungs and pulmonary vasculature (hyperplasia and hypertrophy). This will cause thickening of the blood vessels and will narrow the lumen.
Polycythemia develops and the blood viscosity increases. The increased number of cells will be available to carry O2 but the increased viscosity will increase pressure in the pulmonary vasculature and force the right ventricle to pump harder to maintain the CO level. The right venticle will hypertrophy and eventually weaken, and the patient will develop right heart failure (cor pulmonale).

Type II alveolar cells produce:

-Macrocytes
-Phagocytes
-Surfactant
-CO2

Surfactant

Surfactant is a lipoprotein that functions by increasing surface tension of alveoli and allow alveoli to expand and contract. Some residual pressure should be present in the alveoli at the end of respiration to keep the alveoli open (physiologic PEEP). If surfactant production is impaired, the alveoli's ability to exchange O2 is compromised.

Type I cells line the outside of the alveoli.

If you hear faint breath sounds on the left side of the chest and normal sounds on the right side immediately after your patient is intubated, most likely:

-The patient has a tumor
-The doctor has intubated the esophagus
-The ET is at the carina
-The right mainstem has been intubated

The right mainstem has been intubated

The right mainstem bronchus is somewhat wider and has less of an angle off the mainstem bronchus, so it is much more readily intubated.

John is a 32 year old engineer that has been on hemodialysis for 3 years. He missed his last 2 treatments. He is lethargic, lacks stamina, and is very edematous. His ABGs show: pH 7.30, PaCO2 32, HCO3 17, PaO2, 90.

John's results indicate:

-Metabolic alkalosis
-Respiratory acidosis
-Metabolic acidosis
-Respiratory alkalosis

Metabolic acidosis

More specifically, this ABG indicates an
Uncompensated Metabolic Acidosis.
The pH is low, as is the PaCO2.

You ask a fellow nurse to carry a newly drawn ABG specimen to the lab. She does not plave the sample on ice. What effect will the lack of icing have on the sample:

-None
-It will invalidate the sample
-The pH will rise
-The PaCO2 will rise

It will invalidate the sample

The PaCO2 will rise approximately 3-10 mmHg per hour.
The PaO2 and the pH will decrease.

Your patient must have an ABG. The respiratory therapist says he is out of prepared syringes, so he obtains a syringe into which he places heparin. What effect will too much heparin have on the sample, if any?

-Decreased bicarbonate
-No effect
-Increased PaCO2
-Totally prevent clotting

Decreased bicarbonate

The heparin will have dilutional effects and will decrease the bicorbonate level and the PaCO2.

While the RT is attempting to draw an ABG, you note that he is exerting a lot of force to more the cylinder of the syringe. What effect will this high-friction syringe have on the ABG results, if any?

-It will put the artery into spasm
-Increase the PaCO2
-Decrease the PaO2
-No effect on the results

Decrease the PaO2

Using a vacutainer or a high-friction syringe will create a vacuum. When that occurs, dissolved gases come out of solution, which decreases PaO2 and PaCO2.
The increased effort required to move the cylinder may cause the artery to spasm and make it more difficult to obtain the sample, but will not directly affect the results

The RT asks if the patient has a fever. The possibility of fever will have what effect on the sample:

-The HCO3 will be elevated
-The PaCO2 will rise
-Fever has no effect
-The pH will rise

The pH will rise

Most ABG machines are calibrated to 37'C. If the patient has a fever, the oxyhemoglobin curve will be shifted to the right. More oxygen will be given off to the tissues, so the machine has to be calibrated to account for the higher temperature.

Familial emphysema is a condition that results in a deficiency in:

-Adenosine monophosphate
-Ability to produce mucus
-Alveoli
-Serum alpha-antitrypsin

Serum alpha-antitrypsin

Familial emphysema is extremely rare. Many references estimate the incidence of this condition at only 1 to 3%. It is believed that serum alpha1-antitrypsin destroys lung tissue through enzymatic action. Usually Caucasians of European descent express this disease, which is associated with an autosomal recessive trait. Symptoms usually appear when the patient is a teenager -- a characteristic that can assist in the diagnosis because most emphysema occurs in later years.

People who have emphysema develop chronic hypoxia. Which potential imbalance would be expected with this condition?

-Hypokalemai
-Hypochloremia
-Decreased bicarbonate levles
-Hyponatremia

Hypochloremia

Chronic hypoxia leads to chronic respiratory acidosis. The kidneys then retain bicarbonate in the form of sodium bicarbonate. The bicarbonate is exchanged for sodium chloride. Ammonia is an acid and excess amounts must be removed from the body. This is accomplished by releasing ammonium chloride.
Chronic hypoxia is characterized by increase in bicarbonate levels and a decrease in chloride levels.
Other causes of hypochloremia include NG suction, vomiting, and diarrhea.

Sherie is a 20 year old admitted to your PCU with status asthmaticus. She has been taking Accolate, Allegra, and has been using a Proventil HFA rescue inhaler at home. Today, Sherie was working in her garden when she found that she could not catch her breath. Her bronchospasms worsened, and she was transported to the ED. In the ED, she recieved albuterol, oxygen, and epinephrine without significant improvement. On auscultation, inspiratory and expiratory wheezing with a prolonged expiratory phase is heard throughout the lung fields. Sherie is using accessory muscles for respiration and is tachycardia and tachypneic. She is placed on O2 at 2 L/min via NC and ABGs are drawn. Blood gas results are: pH 7.52, PaO2 106 mmHg, PaCO2 27 mmHg, HCO3 24 mEq/L. These blood gas results show:

-Uncompensated respiratory acidosis
-Compensated metabolic alkalosis
-Compensated metabolic acidosis
-Uncompensated respiratory alkalosis

Uncompensated respiratory alkalosis

The pH is elevated, indicating alkalosis.
The HCO3 is normal.
ThePaCo2 is decreased, indicating respiratory alkalosis.

Sherie is a 20 year old admitted to your PCU with status asthmaticus. She has been taking Accolate, Allegra, and has been using a Proventil HFA rescue inhaler at home. Today, Sherie was working in her garden when she found that she could not catch her breath. Her bronchospasms worsened, and she was transported to the ED. In the ED, she recieved albuterol, oxygen, and epinephrine without significant improvement. On auscultation, inspiratory and expiratory wheezing with a prolonged expiratory phase is heard throughout the lung fields. Sherie is using accessory muscles for respiration and is tachycardia and tachypneic. She is placed on O2 at 2 L/min via NC and ABGs are drawn. Blood gas results are: pH 7.52, PaO2 106 mmHg, PaCO2 27 mmHg, HCO3 24 mEq/L. The doctor now orders Inderal (propanolol). As a nurse, you know that propanolol is contraindicated for asthmatics because:

-It will exacerbate the tachycardia
-It will lead to a severe respiratory acidosis
-PNA may result
-Bronchospasm may worsen

Bronchospasm may worsen

Propanolol may cause bronchospasm. It works by blocking beta-adrenergic effects of the sympathetic nervous system (like bronchodiation). Some beta blockers are cardioselective (e.g. atenolol), and newer agents such as nebivolol, provide for cardioselective beta blockade with vasodilation.

Sherie is a 20 year old admitted to your PCU with status asthmaticus. She has been taking Accolate, Allegra, and has been using a Proventil HFA rescue inhaler at home. Today, Sherie was working in her garden when she found that she could not catch her breath. Her bronchospasms worsened, and she was transported to the ED. In the ED, she recieved albuterol, oxygen, and epinephrine without significant improvement. On auscultation, inspiratory and expiratory wheezing with a prolonged expiratory phase is heard throughout the lung fields. Sherie is using accessory muscles for respiration and is tachycardia and tachypneic. She is placed on O2 at 2 L/min via NC and ABGs are drawn. Blood gas results are: pH 7.52, PaO2 106 mmHg, PaCO2 27 mmHg, HCO3 24 mEq/L. The most probably cause of Sherie's acid-base imbalance would be:

-An adverse effect of albuterol
-A side effect of theophylline
-Hyperventilation
-Hypoventilation

Hyperventilation

Sherie is probably very anxious and hyperventilating because she is unable to get enough oxygen due to bronchial constriction.
Hypoventilation causes a buildup of CO2, leading to respiratory acidosis.
This patient has not received theophylline and Albuterol may cause tachycardia, but not an acid-base imbalance.

Sherie is a 20 year old admitted to your PCU with status asthmaticus. She has been taking Accolate, Allegra, and has been using a Proventil HFA rescue inhaler at home. Today, Sherie was working in her garden when she found that she could not catch her breath. Her bronchospasms worsened, and she was transported to the ED. In the ED, she recieved albuterol, oxygen, and epinephrine without significant improvement. On auscultation, inspiratory and expiratory wheezing with a prolonged expiratory phase is heard throughout the lung fields. Sherie is using accessory muscles for respiration and is tachycardia and tachypneic. She is placed on O2 at 2 L/min via NC and ABGs are drawn. Blood gas results are: pH 7.52, PaO2 106 mmHg, PaCO2 27 mmHg, HCO3 24 mEq/L. Sherie's O2 was increased to 5 L/min via mask. On auscultation, you note that the wheezing is barely audible. This finding may indicate:

-Improvement
-Need to lower O2
-A need for epinephrine
-A worsening condition

A worsening condition

It is unlikely that Sherie's condition is improving. The air becomes trapped in the alveoli and excessive mucus is produced. The patient struggles to breathe and may become exhausted. When the wheezing diminishes or stops altogether, it means air is not able to pass through an opening. This is a medical emergency, and the patient may need to be intubated. A lot of controversy surrounds the issue of intubation asthmatics, because this procedure may cause barotrauma, hyperinflation, and cardiac compromise.

A possible treatment to best improve airflow in status asthmaticus is:

-Bromex
- Heliox
-Norepinephrine
-Nebulizer treatments

Heliox

Heliox is a helium-oxygen mixture that can help with the delivery of inhaled medications, thereby decreasing the work of breathing.

Norepinephrine is a vasocontrictor.
Nebulizers may also work, but if the patient's condition is compromised the effectiveness is minimal at best.

Sherie is a 20 year old admitted to your PCU with status asthmaticus. She has been taking Accolate, Allegra, and has been using a Proventil HFA rescue inhaler at home. Today, Sherie was working in her garden when she found that she could not catch her breath. Her bronchospasms worsened, and she was transported to the ED. In the ED, she recieved albuterol, oxygen, and epinephrine without significant improvement. On auscultation, inspiratory and expiratory wheezing with a prolonged expiratory phase is heard throughout the lung fields. Sherie is using accessory muscles for respiration and is tachycardia and tachypneic. She is placed on O2 at 2 L/min via NC and ABGs are drawn. Blood gas results are: pH 7.52, PaO2 106 mmHg, PaCO2 27 mmHg, HCO3 24 mEq/L. Sherie's O2 was increased to 5 L/min via mask. Sherie now needs immediate intubation and is placed on mechanical ventilation, and then transferred to the ICU. The doctor uses pancuronium (Pavulon) to paralyze the respiratory muscles. Which of the following drugs will counteract the effects of Pavulon?

-Atropine
-Narcan
-Neostigmine
-Regitine

Neostigmine

Neostigmine is an enzyme that prevents the breakdown of avetylcholine into its enzyme. This medication also improves impulse transmission. Sometimes Neostigmine causes bradycardia and increases bronchial secreations, so atropine may be used with this agent to mitigate its effects.

Narcan is an opioid antagonist.

Hugh, a 47 year old patient with severe bronchitis, has been treated with a non-rebreather mask for 5 days. He is exhibiting increased distress with chest discomfort, restlessness, a dry hacking cough with dyspnea, and numbness in his extremities. PFTs (pulmonary function tests) indicate a decreased vital capacity (VC), decreased compliance, and decreased functional residual capacity (FRC). As a nurse caring for this patient, you should:

-Prepare for intubation with 100% FiO2 (fraction of inspired oxygen)
-Administer Lasix 40 mg IV
-Take the patient for a CT and prepare to give tPA
-Check the pulse oximeter correlation with an arterial blood gas and decreasethe FiO2

Check the pulse oximeter correlation with an arterial blood gas and decreasethe FiO2

Hugh is exhibiting signs and symptoms of O2 toxicity after 5 days of O2 therapy at >50% FiO2.
Non-rebreather masks provide a minimum of 60% FiO2 at 6 L/min.
An ABG would show an increased PaO2 >100 mm Hg, ruling out respiratory failure (PaO2 <60) that would require intubation. The dry, hacking cough rules out pulmonary edema and the need for Lasix.
The numbness in the extremeties results from the presence of oxygen radicals in the blood, rather than a neurologic impairment that would indicate the need for a CT scan with possible tPA administration.

Eileen, a 30 year old female, was admitted 3 days ago with a right fractured femure of 2 ribs. She has been on O2 at 60% since admission. During you admission, you note a temperature of 100'F, heart rate of 120, RR of 30, increased coiugh, and decreased breath sounds on the right side without tracheal deviation. You suspect her symptoms are the result of:

-Pulmonary edema
-Atelectasis
-Pneumothorax
-Sepsis

Atelectasis

Three days of high FiO2 has resulted in a nitrogen washout, resulting in atelectasis. Nitrogen's high partial pressure is necessary to maintain alveolar inflation. It is important to titrate FiO2 to maintain O2 saturation within a prescribed range when O2 therapy is utilized.
Pulmonary edema would result in coarse breath sounds.
With unilateral pneumothorax, tracheal deviation might be observed.
Sepsis would not necessarily present with diminished breath sounds, but additional findings could include increased purulent secretions, coarse breath sounds, and altered lab results.

As patients age, chest wall compliance decreases. One of the reasons for this change is that:

-Total lung capacity decreases
-Costal cartilage degenerates
-Arterial oxygen tension increases
-Residual volume decreases

Costal cartilage degenerates

Sometimes the costal cartilage becomes calcified with age. Vertebrae develop osteoporosis, and a degree of kyphosis can occur. Weight gain is common and posture is affected. The chest wall compliance decreases, as does vital capacity. Residual volume increases, PaO2 decreases, and PaCO2 increases.

The cells that are responsible for forming a barrier for alveoli are:

-Macrophages
-Type II alveolar epithelial cells
-Type I alveolar epithelial cells
-Cilia

Type I alveolar epithelial cells

Type I cells line the outside of the alveoli. These cells, which maintain the blood-gas interface, are easily inflamed by inhaled toxins or heated air.

Type II cells produce surfactant.

Anatomic dead space isreferred to as:

-Minute ventilation
-Wasted ventilation
-Physiologic dead space
-Conducting airways

Conducting airways

Conducting airways are ventilated, but perfusion (gas exchange) does not occur.

Wasted ventilation is the amount of ventilation that does not participate in gas exchange.

The oxyhemoglobin dissociation curve is:

-A graphic representation showing the relationship between dissolving oxygen and the affinity for oxygen by the hemoglobin molecule
-A graphic representation of carbon dioxide content verses oxygen content in arterial blood
-A measure of methemoglobin
-A way to calculate gas transport across the alveoli

A graphic representation showing the relationship between dissolving oxygen and the affinity for oxygen by the hemoglobin molecule

The oxyhemoglobin dissociation curve reflects physiological circumstances and their effect on the hemoglobin's affinity for oxygen.

If the oxyhemoglobin curve shifts to the right, one factor that will affect this shift is:

-A decreased CO2
-A decreased pH
-A decrease in temperature
-A decrease in 2,3-DPG

A decreased pH

A shift to the right means hemoglobin has less affinity for oxygen.

2,3-Diphosphoglyceride (2,3-DPG) is needed to help force O2 off the hemoglobin molecule.
If 2,3-DPG levels decrease, the hemoglobin will hang onto O2.

If the temperature increases, the tissues need more O2.

If the PCO2 becomes elevated, the tissues need more O2.

If the oxyhemoglobin dissociation curve shifts to the left, which of the following would precipitate this change?

-Increased temperature
-Increased PaCO2
-Increased 2,3-DPG
-Increased pH

Increased pH

When the oxyhemoglobin dissociation curve shifts to the left, it means that hemoglobin holds onto oxygen.

In this circumstance, 2,3-DPH is lacking, CO2 would be decreased, and temperature would be decreased.

Tissues would not need as much O2.

Your patient has pulmonary HTN. The doctor has been utilizing diuretics without much effect. Which of the following therapies might be effective?

-Digitaliz
-Increased hydration
-Nitric oxide
-Neostigmine

Nitric oxide

Nitric oxide is a vasodilator and may be administered by mask, ET tube or tracheostomy. The nitric oxide reduced blood pressure in the pulmonary circulation.

Chronic hypoxia usually results in which of the following electrolyte imbalances?

-Decreased chloride
-Decreased potassium
-Decreased calcium
-Decreased bicarbonate

Decreased chloride

The kidneys try to correct the imbalance by retaining bicarbonate. Chronic hypoxia results in increased CO2 (chronic respiratory acidosis). The bicarbonate exchanges for the chloride to maintain a balance.

If you were auscultating lung sounds and you can clearly hear the patient's spoken word through the stethoscope, this is known as:

-Egophony
-A friction rub
-Whispered pectroliloquy
-Bronchophony

Bronchophony

Normally, lung sounds are somewhat muffled. Sounds may be heard clearly if the lung is consolidated.

If a whisper is transmitted, it is ususual and may also indicate consolidation.

Egophony is a sound that changes in intensity; if the patient says "E," it is heard as an "A."

What is the interpretation for the following ABG:

pH 7.22
PO2 93 mm Hg
PaCO2 52 mm Hg
HCO3 23 mEq/L

-Uncompensated respiratory acidosis
-Compensated metabolic acidosis
-Uncompensated metabolic alkalosis
-Compensated respiratory acidosis

Uncompensated respiratory acidosis

The pH shows that the patient's condition is uncompensated and acdotic (<7.35), the elevated CO₂ indicates that the condition is respiratory (>45 mm Hg), and the bicarbonate is normal (22-26 mm Hg). Hence the patient has uncompensated respiratory acidosis.

Your patient had 1250 ml of pleural effusion removed via thoracentesis and immediately began coughing and was dyspneic. You believe he has developed:

-A pneumothorax
-Reexpansion pulmonary edema
-Cardiac tamponade
-Hemothorax

Reexpansion pulmonary edema

Removal of large amounts of pleural fluid (greater than 1000 ml) increases negative intrapleural pressure. Edema occurs when the lung does not reexpand. The patient develops a severe cough and dyspnea. If these symptoms occur during thoracentesis, the procedure should be stopped.

Falsely low readings on a pulse oximeter may be due to :

-Electronic interference from hemodialysis
-Fever
-Vascular dyes
-Polycythemia

Vascular dyes

Certain dyes interfere with the sensor's ability to conduct red and infrared light. These dyes include methylene blue, fluroscein, indocyanine green, and indigo carmine.

Joseph's tracheostomy tube cuff has been requiring increasing pressures all shift to maintain a good air seal. What is a possible complication?

-Tracheal stenosis
-Air embolus
-Tracheal atrsia
-Erosion of the innominate artery

Erosion of the innominate artery

Erosion of the innominate artery is probably when the tip of the tube rubs agaist tissue or the stoma is too low. The trachea is somewhat oval, whereas the tube and cuff are circular. THe tube may have been loose and allowed for more than the usual movement of the tube.

A contraindication for use of a nasal trumpet would include:

-Use as an alternative to oral intubation
-Basilar skull fracture
-Use with unconscious patients
-A situation in which the nasal trumpet might be easily dislodged

Basilar skull fracture

The nasopharyngeal airway should not be used on patients with basial skull fractures, sepsis, bleeding disorders, malformations or injuries to the nares, or nasal obstructions. Use this type of airway with caution in patients who arereceiving anticoagulants, fibrinolytics, or thrombolytics.

The RT tells you he is covering another unit and cannot perform postural drainage on your patient. He says your patient needs the left upper lobes drained if possible. The correct position to help this patient is:

-Semi-reclining
-Flat with hips elevated
-Supine
-Flat on left side

Semi-reclining

A semi-reclining or upright position will promote upper lobe drainage.
Fluid or secretions will collection if the patient is positioned flat.

The RT has just given your patient an aerosol treatment. Which of the following conditions is contraindicated for this treatment:

-Pleural effusions
-Head injury
-Asthma
-Stridor

Head injury

If the head is lower than the body intracranial pressure is increased. It is also best to avoid postural drainage in a woman in the last 2 to 3 month of pregnancy, because the baby will shift towards the lungs and may cause respiratory distress. It is also a good idea to wait an hour after the patient eats before giving an aerosol treatment so as to avoid nausea, vomiting, and possible aspiration.

BiPAP is somewhat useful in acute respiratory distress syndrome (ARDS) because:

-BiPAP decreases cardiac output
-BiPAP decreases venous return so the lungs drain more effectively
-BiPAP prevents barotrauma
-BiPAP can open collapsed alveoli

BiPAP can open collapsed alveoli

Answers A, B, and C are all complications of BiPAP. BiPAP must be regulated so as not to cause barotrauma, yet still keep alveoli from collapsing during expiration. The patient may have to be mechanically ventilated at some point if the BiPAP is not effective.

Patients at risk for thrombosis formation have been classified by a trio of factors known as:

-Beck's Triad
-Belchod's Triad
-Virchow's Triad
-Goodman's Triad

Virchow's Triad

Virchow's triad consists of venous stasis, hypercoagulability of blood, and injury to vascular endothelium.

Beck's Triad is indicative of cardiac tamponade.

An example of a beta₂-adrenergic agonist would be:

-Brethine
-Mucomyst
-Alupent
-Atrovert

Brethine

Beta₂-adrenergic agonists include Brethine, Bronkosol and Proventil. These medications are preferred because they cause fewer cardiovascular effects in patients with respiratory failure. They are selective for respiratory stimulation.
Epinephrine and Isuprel are non-respiratory selective.
Atrovent is classified as a parasympatholytic

During a cardiopulmonary arrest, you note that the patient is being forcefully ventilated by the RT using a bag-valve mask device. You know the patient is at risk for:

-Alveolar collapse
-Barotrauma
-Cardiac tamponade
-Hemothorax

Barotrauma

The ventilatory pressures cause by excessive force with the BVM can exceed the intrathoracic and intrapleural pressures, causing barotrauma. Such excessive pressures can damage several different organs in the thorax and even organs in the abdomen. The lungs are susceptible to collapse (pneumothorax). Barotrauma may also damage major blood vessels.

Signs and symptoms of a pulmonary embolus can include:

-A normal EKG or sinus bradycardia
-Pleuritic chest pain and decreased cardiac output
-ABGs showing respiratory acidosis and increased respiratory rate
-Decreased pulmonary pressures.

Pleuritic chest pain and decreased cardiac output

An acute pulmonary embolism can be associated with right heart failure. The patient may have chest pain, dyspnea, tachycardia, hypotension, shock and possibly coma.

Your patient is undergoing a cardiopulmonary arrest. The patient is being ventilated with a BVM device and oropharyngeal airway is in place. A continuous end-tidal CO₂ (PET CO₂) device is built into the BVM. The doctor suspects the patient has suffered a pulmonary embolism. An expected change in parameters would include:

-Increased PaO₂
-Decreased CVP
-Decreased PET CO₂
-Increased PaCO₂

Decreased PET CO₂

The patient will have a sudden decrease in the PET CO₂ due to loss of blood flow in the pulmonary vasculature. The decrease in blood flow increases dead space, with a resultant decrease of the PET CO₂

On an EKG, an extensive pulmonary embolism may show:

-Tall, peaked T waves in leads II, III and AVF
-Sinus bradycardia
-Inverted T waves in leads V6-V9
-Complete heart block

Tall, peaked T waves in leads II, III and AVF

In addition, in pulmonary embolism, the EKG may actually be normal, may show right axis deviation, T-wave inversion (leads V1-V4) amd ST-segments depression. New-onset atrial fibrillation and RBBB may also occur.

Hannah was admitted to the ICU with a fever of 102.3'F, headache, dyspnea, dry cough, and chills. Her lab results indicated a low while blood count, low platelets, and raised C-reactive protein. Hannah's history includes a recent trip to a remote Chinese village within the past 2 weeks. You suspect Hannah may have:

-PNA
-SARS
-Influenza
-Pericarditis

SARS

Severe acute respiratory syndrome (SARS) is a community acquired PNA. Its incubation period is usually 2-14 days, and the pathogen -- SARS associated coronavirus -- is spread via droplets. SARS is usually acquired in underdeveloped areas. THere is no cure and symptoms are treated as they appear. It is incumbent on the nurse to make certain that the patient is placed in a negative pressure isolation room and that an N-95 respirator mask is used.

Which of the following statements is true about a pulmonary embolism?

-Respiratory acidosis will occur
-Heparin is used to dissolve clots
-Normal D-dimer results can rule out a pulmonary embolism
-Metabloic alkalosis will develop

Normal D-dimer results can rule out a pulmonary embolism

If the D-dimer is elevated it may be caused by multiple other conditions. A normal D-dimer rules out a pulmonary embolism.

Hyperventilation will occur subsequent to hypoxemia, so respiratory alkalosis will occur.

Heparin does not dissolve existing clots.

Gail was admitted to the PCU following a fall from a stepstool. She complains of stabbing substernal pain each time she changes her position. Gail has been diagnosed with pneumomediastinum. A common significant finding with this diagnosis is:

-Cullen's sign
-Grey-Turner's sign
-Hamman's sign
-Handes' sign

Hamman's sign

Hamman's sign is a "crunching" sound or a slight clicking sound with each heart sound, auscultated over the apex of the heart.

Severe carbon monoxide poisoning occurs with carboxyhemoglobin levels are higher than which of the following percentages?

-10-15%
-20-40%
-40-50%
-50-60%

20-40%

If carbon monoxide levels are above 60%, the patient will be comatose and will probably die.

Smokers often have CO levels of 5-10%.

Normal CO levels in nonsmokers are less than 2%.

Carbon monoxide has an affinity for hemoglobin throught to be 200-300 times greater than that of oxygen. Elimination of carbon monoxide occurs via the:

-Kidneys
-Liver
-Spleen
-Lungs

Lungs

In cases of severe carbon monoxide poisoning, hyperbaric therapy must be utilized to force the molecure off the hemoglobin. The CO is then eliminated by the lungs.

Bernard lost his home to a fire this morning. He was burned on the chest and neck while trying to put out the fire. He is dyspneic and has soot on his face, and his eyebrows and nares are singed. The priority during treatment is to:

-Maintain cardiac output
-Maintain airway patency
-Treat burned areas
-Obtain ABGs and a carboxyhemoglobin level

Maintain airway patency

Airway patency is always a priority. Bernard probably inhaled superheated air and toxins. Most of the products found in a home will give off carbon monoxide when burned. These toxins, plus the CO may cause edema of the air passages

Increases in lung compliance occur with:

-Pulmonary edema
-Pleural effusions
-Obesity
-Emphysema

Emphysema

Answers A, B, and C decrease lung compliance. Other factors that decrease compliance include atelectasis, fibrotic changes, abdominal distention, pain (causes splinting), and flail chest (pain and loss of structure).

Which of the following statements about laryngeal mask airways is true?

-A laryngeal mask airway may be inserted by any nurse.
-A laryngeal mask airway may cause hoarseness after removal
-The patient must have an absent gag reflex
-A laryngeal mask airway eliminates the risk of aspiration

The patient must have an absent gag reflex

The patient must have an absent gag reflex. The laryngeal mask airway (LMA) cannot be inserted by nurses unless they have received specialized training. The LMA does not usually cause hoarseness because it does not pass through the vocal cords. There is a high risk of aspiration with use of the LMA.

Which of the following drugs would be considered a mucolytic agent?

-Atropine
-Terbutaline
-Acetyl-cysteine
-Albuterol

Acetyl-cysteine

Acetyl-cysteine contains a sulfide group that effectively splits disulfide bonds in mucin molecules, thereby reducing the viscosity of the mucus.

Atropine is an anticholinergic.
Terbutaline and albuterol are B₂-agonists.

Side effects of aceytl-cysteine include:

-Bronchospasm
-Headache
-Hypertension
-Red urine

Bronchospasm

Thinning mucus may promote excessive coughing with resultant bronchospasm. Additional side effects include rhinorrhea, stomatitis, nausea, and vomiting.

One of the most effective ways to relieve bronchospams is to administer:

-Adrenalin
-An antihistamine
-Prednisone
-A Beta₂-receptor agonist

A Beta₂-receptor agonist

Beta₂-receptor agonist lowers cellular calcium levels and relaxes bronchial smooth mucles. Selective B₂-receptor agonists do not produce cardiac stimulation. The cardiac stimulation can result in tachycardia and reduced cardiac output.

Which of the following drugs is a methylzanthine?

-Prenisone
-Theophylline
-Atropine
-Accolate

Theophylline

Methylzanthines, which include caffeine and theobromine, are in important class of drugs. They can be found in coffee, tea and cocoa. This class of drugs, when given in low doses, stimulates cortical arousal. In higher doses, they cause insomnia. Methylzanthines can cause tachycardia, increased production of gastric acid and digestive enzymes, and inhibit histimine release.

To determine whether your patient has a genetic predisposition for malignant hyperthermia, which of the following drugs might be used:

-Holothane
-Caffeine
-Accolate
-Singulair

Caffeine

In malignant hyperthermia, the use of anesthetic agents such as holothane cause muscles to contract and the patient to become hypothermic. Caffeine is used diagnostically in such cases because, when given at high doses, it can contract muscles without the danger of depolarizing cell membranes.
The antidote for malignant hyperthermia is dantrolene.

During a cardiac arrest, your patient aspirated gastric contents. Which of the following statements is true regarding this type of aspiration:

-If the pH of the material is <2.5, necrosis will be minimal
-The patient will always develop ARDS
--There is little danger of atelectasis

Onset of symptoms usually occurs gradually

Symptoms have gradual onset. The patient may develop ARDS, but not always.
If the pH is >2.5, very little necrosis will occur.
If the pH is <2.5, there is probability of pulmonary edema, necrosis, bleeding and atelectasis.

Devin was admitted from abrupt-onset fever, chills, vomiting, diarrhea, and headache that developed in the past 24 hours. Devin recently had been on a cruise to Barbados. Devin is probably suffering from:

-A Pseudomonas infection
-Influenza
-A Klebsiella infection
-Legionnaire's disease

Legionnaire's disease

Devin has the classic symptoms of Legionnaire's disease. If left untreated, this infection may lead to hypotension, acute kidney injury, shock, respiratory failure, and death.

Placement of a central line via subclavian vein may cause:

-Cardiac tamponade
-An open pneumothorax
-A tension pneumothorax
-Limb pain

An open pneumothorax

By definition, an open pneumothorax exists because air enters the pleural cavity from the atmosphere. The hole made into the subclavian vein allows for air to pass from the atmosphere into the pleural cavity.

When the resident attempts to place a central line, air is accidently introduced into the line when the IV tubing becomes disconnected. The best position to place this patient to minimize venous air embolism is:

-Reverse Trendelenburg
-On the right side
-Trendelenburg with left decubitus tilt
-On the left side

Trendelenburg with left decubitus tilt

This postion will minimize the chance of any air migrating through the heart and into the lungs.

The definitive study for determination of thrombolic emboli is:

-Pulmonary ventilation-perfusion scan (VQ scan)
-Mixed venous oxygen saturation
-Pulmonary angiography
-PAWP

Pulmonary angiography

A pulmonary angiography involves catheterization of the right ventricle, followed by injection of dye into the pulmonary artery. The pulmonary vasculature is easily seen with this study. The location of the embolus is readily identified because the dye trail comes to a sudden end.

Risk factors for thrombolic emboli include:

-A patient who is one week postpartum
-Carcinoma
-Long bone fractures
-Heparin administration

Carcinoma

Neoplasms, obesity, trauma, dysrhythmias, CHF, and prolonged immobility are also factors.

A venous air embolism may be caused by:

-Hemodialysis
-Pulmonary artery catheter
-Radial arterial catheter
-Peritoneal dialysis

Hemodialysis

Other postential causes include central and pulmonary artery catheters, endoscopy, and automatic pressure-driven injectors.

Blood gases you would expect to see with thrombotic emboli are:

-pH 7.42, PaO₂ 88, PaCO₂ 28, HCO₃ 22
-pH 7.50, PaO₂ 74, PaCO₂ 52, HCO₃ 24
-pH 7.32, PaO₂ 86, PaCO₂ 29, HCO₃ 26
-pH 7.32, PaO₂ 90, PaCO₂ 30, HCO₃ 24

pH 7.50, PaO₂ 74, PaCO₂ 52, HCO₃ 24

These results show Respiratory Acidosis with hypoxemia

Barbara was admitted for multiple fractures and contusions following an MVA this evening. She complains of dyspnea and petechiae are noted. Barbara probably has:

-A pulmonary embolus
-Thrombocytopenia
-A venous air embolus
-A fat embolus

A fat embolus

Fractures, usually to long bones, can release free fatty acids, which cause vasculitis. Fat flobules float around in the circulation abd obstruct the pulmonary vasculature.

The best position for a patient with ARDS is:

-Prone
-On the right side
-On the left side
-Supine

Prone

Prone positioning is the best postion to promote drainage and oxygenation. It is often the most difficult position to achieve without proper lifting and safety devices.

Fluid therapy in ARDS is directed towards:

-Keeping a high caridac output state
-Maintaining a low protein content
-Maintaining hyponatremia
-Maintaining a low circulating fluid volume

Maintaining a low circulating fluid volume

The fluid volume is kept low. If too much fluid is present, leakage may occur through demaged capillaries into the interstitial space.

Pulmonary hypertension is usually defined by the level of the mean pulmonary arterial pressure (MPAP). A diagnosis of pulmonary hypertension can be made if the MPAP is:

-3-5 mmHg
-5-9 mmHg
-10-20 mmHg
->20 mmHg

>20 mmHg

The strict definition of pulmonary hypertension is that MPAP is greater than 20 mmHg.

The hallmark sign of asthma is:

-PEFR 100-125
-FEF of 80%
-Decreased FEV₁
-Wheezing

Decreased FEV₁

The forced vital capacity (FVC) is the total amount of gas exhaled as forcefully and rapidly as possible after taking a maximal inspiration. The result should be above 80%. The forced expiratory volume (FEV) is how much gas is exhaled during the first seconds of effort. This amount should be 75% of more of the predicted normal value. In individuals with asthma, this value is decreased because of obstruction.

When assessing a patient with a chest tube drainage system, which of the following statements would be correct:

-Chech for subcutaneous emphysema around the insertion site bu auscultation
-If using a Pleur-Evac with auto-transfusion connection, make certain all clamps are open
-The average chest tube size for an adult is 20Fr.
-If using a chest tube drainage system with a one-way valve and suction, water is required to maintain the seal.

If using a Pleur-Evac with auto-transfusion connection, make certain all clamps are open

When using an auto-transfusion drainage system, make sure to connect the system per the manufacturer's recommendations. Most connections will be color-coded to simplify the connection process. Clamps must remain open to allow for blood collection and to prevent an increase in itrathoracic pressures.

Subcutaneous air shoud be checked by palpation and borders marked for further monitoring.

The average adult-size catheter is 28 or 36 Fr.

If a one-way valve system and suction is used, water is not required to maintain a seal because the valve performs this function.

The oxyhemoglobin dissociation curve may be shifted to the right by:

-Alkalosis, hyperthemia, hypercapnia
-Acidosis, hypercarbia, hyperthermia
-Acidosis, hypocarbia, hypothermia
-Alkalosis, hypothermia, hypercapnia

Acidosis, hypercarbia, hyperthermia

These will all lead to a right shift in the oxyhemoglobin dissociation curve. Hemoglobin has a decreased affinity for oxygen and enhances tissue uptake of oxygen.

Which of the statements is true about esophageal detection devices (EDDs):

-An EDD reduces silent aspiration
-An EDD will have a beige color when gas exchange is adequate
-An EDD is more reliable than a CO2 detector in a pulseless patient
-A false-positive result may occur if the patient recently ingested a carbonated beverage

A false-positive result may occur if the patient recently ingested a carbonated beverage

If a patient has ingested a carbonated beverage, the CO2 production/ accumulation within the stomach would lead to inflation of the esophageal detection device (EDD) and a false-positive reading the the ETT placement in the airway. It is best to use auscultation, observation, and improvement in vital signs as primary techniques to confirm endotracheal tube placement and EDD and CO2 detectors as secondary methods.

Research has shown that use of normal saline does not thin secretions and may cause which of the following adverse side effects:

-anxiety
-depression
-decreased mean arterial pressure
-bronchdilation

anxiety

Research into the use of normal saline in tracheal suctioning has proven that normal saline causes anxiety, increases the patient's risk for hospital acquired PNA and may cause bronchconstriction. Current recommendations focus on dry suctioning, frequent oral care, balanced hydration, and position changes as means to prevent complications associated with intubation and mechanical ventilation.

Your patient is receiving an antibiotic intervenously for PNA. The antibiotic is mixed as 1 g in 100 ml of D5W. You need to administer the medication over 40 minutes. The IV tubing you have delivers 15 gtt/mL. How many drops per minute should you set your infusion pump to deliver:

-38 gtt/min
-16 gtt/min
-32 gtt/min
-19 gtt/min

38 gtt/min

100 mL / 40 minutes = 2.5 (mL/min)
2.5 (mL/min) X 15 (gtt/mL) = 37.5 or 38 gtt/min

Which of the following conditions will decrease the productions of 2,3-DPG?

-Hypothyroidism
-Hypoxemia
-Congential heart disease
-Anemia

Hypothyroidism

Hypothyroidism, banked blood transfusions, malnutrition, hypophospatemia and hexokinase deficiency will all cause 2,3-DPG to decrease.

An increase in 2,3-DPG will been seen with anemia, congential heart disease, hyperthyroidism, and chronic hypoxemia.

Central cyanosis is usually seen when the Hgb level is:

-2 g/dL
-5 g/dL
-8 g/dL
-10 g/dL

5 g/dL

Usually, central cyanosis is seen when the level of deoxygenated Hgb reaches 5 g/dL. The cyanosis can been seen on the lips and possibly on the mucous membranes.
It can be an early sign of hypoxia in patients with polycythemia. These patients will be cyanotic with 5 g/dL is desaturated. Sometimes these patients are called "blue bloaters."
In anemic patients, this is a late sign and they will not necessarily be cyanotic.

A side effect of succinylcholine is:

-Hypokalemia
-Malignant hypothermia
-Hypotension
-Cardiac arrest

Cardiac arrest

Succinylcholine combines with acetylcholine to cause smooth muscle relaxation. Prolonged use may cause a change in blocking action and result in potassium-regulated alterations in electrical activity.
Other side effects of succinylcholine include malignant hyperthermia and hypertension or hypotension, hyperkalemia, anaphylaxis, and increased intraocular pressure.

Vecuronium (Norcuron) is eliminated primarily via the:

-Renal glomerulus
-Spleen
-Hepatic/ biliary system
-Hoffman elimination

Hepatic/ biliary system

Norcuron is eliminated via the hepatic/ biliary system. Use with caution in patients with known or suspected hepatic or biliary compromise, such as cirrhosis or hepatitis and may take up to two times as long to clear patients' systems.

Asthma patients may receive steroids and neuromuscular blocking agents, so these patients are at increased risk for:

-Renal failure
-Hypertension
-Hepatic failure
-Prolonged muscle weakness

Prolonged muscle weakness

Uncontrolled asthma symptoms during an attack may lead to prolonged and extensive muscle use to maintain independent respirations. This prolonged effort may results in respiratory failure due to respiratory muscle fatigue. Administration of a neuromuscular blocking agent further inhibits the smooth muscle retractions. Long-term steroid use has been linked to muscle wasting. Ventilatory weaning may be prolonged as respiratory muscles recover from both the disease process and the pharmacologic intervention.

The FiO2, for a nasal cannula set at a rate of 6 L/min is:

-24%
-30%
-21%
-40%

40%

The nasual cannula is generally considered a low-flow oxygen device unless connected to a high-flow system. If using a flow >4 L/min, the oxygen should be humidified to prevent drying the mucosal membranes.

A non-rebreathing mask can deliver what % of O2 when the O2 flow rate is 10-15 L?

-30-40%
-24-40%
-60-80%
-50-60%

60-80%

If both exhalation ports have one-way valves, then a flow of near 100% oxygen may be reached. To prevent suffocation in patients where the oxygen is disconnected, non-rebreathing masks now have only one one-way valve to prevent/ limit inhalation of room air. This results in decreasing the highest concentration of actual inspired oxygen to 60-80%.

Pulse oximetry readings are considered unreliable when oxygen saturation falls below:

-60%
-90%
-55%
-70%

70%

The accuracy of pulse oximetry is affected by patient motion, low perfusion, venous pulsation, light, prro probe positioning, edema, anemia, and carbon monoxide levels. It is important to compare pulse oximetry values against ABGs to validate a value of less than 70%.

A factor that increases pulmonary vascular resistance is:

-Prostaglandin therapy
-Sepsis
-Hypoxia
-Hypovolemia

Sepsis

Sepsis may result in lung tissue injury and , consequently, increased pulmonary vascular resistance (PVR).
Prostaglandin and oxygen therapies result in pulmonary vasodilatation and decreased PVR.

A cause of decreased SVO2 would be:

-An increased metabolic rate
-Sedation
-A decerased metabolic rate
-An increased cardiac output

An increased metabolic rate

Increased metabolic rate would increase O2 uptake by tissues, resulting in a lower value as measured by venous blood gases.
The other answers result in a lower tissue oxygen requirement and, therefore, higher values of oxygen remaining in the bloodsteam.

When an oral endotracheal tube (ETT) is properly positioned in an adult, the centimeter mark will usually be _____ for women at the front teeth.

-14 cm
-21 cm
-23 cm
-25 cm

21 cm

For women, the average depth for an ETT at the lips is 21 cm when using a 7 or 8 Fr ETT.
The average depth for men is 23 cm at the lip when using a 8 or 8.5 Fr ETT.
Assessment documentation should always include both of these values, in case the tube becomes dislodged at any time during respiratory support.

The normal anterior-posterior diameter of the thorax ratio to the lateral diameter is a ratio of

-1:1
-2:5
-2:3
-1:2

1:2

The normal ratio is derived from the lateral diameter, so the ratio is 1:2. This information is handy to know because if you measures these distances, you can sometimes note early changes in the thorax, possibly due to emphysema or COPD.

A common site for the placement of electrodes for a peripheral nerve is on the:

-Posterior tibial
-Medial nerve
-Temporal nerve
-Radial nerve

Posterior tibial

Stimulation of the posterior tibial nerve results in plantar fixation of the great toe. Other locations for peripheral nerve stimulation electrode placement include the ulnar nerve and the facial nerve.

Muscles will stop moving in the folloing order in response to neuromuscular blocking agents:

-Abdomen, glottis, extremities, face, eyes
-Glottis, extremities, face, abdomen, eyes
-Eyes, face, extremities, abdomen
-Glottis, intercostals, extremities, neck

Eyes, face, extremities, abdomen

The progression in which movement of muscles stops is: eyes, face, neck, extremities, abdomen, glottis, intercoastals, and diaphragm.

It is important to recall that muscle movement will return in the reverse order.

The usual goal for a patient having neuromuscular blockade during mechanical ventilation is on to two twitches, indicating _____ to _____ block.

-85 to 90%
-60 to 70%
-40 to 50%
-25 to 40%

85 to 90%

One to two twitches represents 85 to 90% blockage. It is important to remember that different muscles may respond differently to neuromuscular blocking agents. As muscles of the fave will stop before the diaphragm, one might check twitches on the face and an extremity rather than just the face.

Analyze the following arterial blood gas results.

pH 7.38
CO2 27
HCO3 16

-Normal
-Compensated respiratory acidosis
-Compensated metabolic acidosis
-Uncompensated respiratory alkalosis

Compensated metabolic acidosis

These findings indicate compensated metabolic acidosis.
The pH is between 7.35 and 7.45, so the value is Compensated.
Because the value is closer to 7.35, it is considered Acidosis.
To determine whether the acidosis is respiratory or metabolic, find the value that represents acidosis: HCO3 < 22 mEq/L.

Normal Values:
pH is between 7.35 and 7.45
CO2 is between 35 and 45 mm Hg
HCO3 is between 22 and 26 mEq/L

Analyze the following arterial blood gas results.

pH 7.46
CO2 34
HCO3 24

-Normal
-Compensated respiratory acidosis
-Compensated metabolic acidosis
-Uncompensated respiratory alkalosis

Uncompensated respiratory alkalosis

The pH is greater than 7.45, so the value is Uncompensated Alkalosis.
To determine whether the alkalosis is respiratory or metabolic, find the value that represents alkalosis: CO2 <35 mm Hg.

Normal Values:
pH is between 7.35 and 7.45
CO2 is between 35 and 45 mm Hg
HCO3 is between 22 and 26 mEq/L

Analyze the following arterial blood gas results.

pH 7.18
CO2 40
HCO3 15

-Normal
-Compensated respiratory acidosis
-Uncompensated metabolic acidosis
-Uncompensated respiratory alkalosis

Uncompensated metabolic acidosis

The pH is less than 7.35, so the value is Uncompensated Acidosis.
To determine whether the acidosis is respiratory or metabolic, find the value that represents acidosis: HCO3 < 22 mEq/L.

Normal Values:
pH is between 7.35 and 7.45
CO2 is between 35 and 45 mm Hg
HCO3 is between 22 and 26 mEq/L

Analyze the following arterial blood gas results.

pH 7.56
CO2 25
HCO3 34

-Uncompensated (mixed) respiratory/ metabolic alkalosis
-Compensated respiratory acidosis
-Compensated metabolic acidosis
-Uncompensated respiratory alkalosis

Uncompensated (mixed) respiratory/ metabolic alkalosis

The pH is greater than 7.45, so the value is Uncompensated.
To determine whether the alkalosis is respiratory or metabolic, find the value that represents alkalosis: HCO3 > 26 mEq/L and CO2 < 35 mm Hg, meaning the cause of the alkalosis is both respiratory and metabolic in nature.

Normal Values:
pH is between 7.35 and 7.45
CO2 is between 35 and 45 mm Hg
HCO3 is between 22 and 26 mEq/L

Analyze the following arterial blood gas results.

pH 7.42
CO2 36
HCO3 23

-Compensated respiratory acidosis
-Normal
-Compensated metabolic acidosis
-Uncompensated respiratory alkalosis

Normal

The pH is between 7.35 and 7.45
The CO2 is between 35 and 45 mm Hg
The HCO3 is between 22 and 26 mEq/L

Normal Values:
pH is between 7.35 and 7.45
CO2 is between 35 and 45 mm Hg
HCO3 is between 22 and 26 mEq/L

Analyze the following arterial blood gas results.

pH 7.49
CO2 30
HCO3 22

-Uncompensated metabolic alkalosis
-Compensated respiratory acidosis
-Compensated metabolic acidosis
-Uncompensated respiratory alkalosis

Uncompensated respiratory alkalosis

The pH is greater than 7.45, so the value is Uncompensated Alkalosis.
To determine whether the alkalosis is respiratory or metabolic, find the value that represents alkalosis: CO2 ,35 mmHg

Normal Values:
pH is between 7.35 and 7.45
CO2 is between 35 and 45 mm Hg
HCO3 is between 22 and 26 mEq/L

Analyze the following arterial blood gas results.

pH 7.37
CO2 68
HCO3 38

-Uncompensated metabolic alkalosis
-Compensated respiratory acidosis
-Compensated metabolic acidosis
-Uncompensated respiratory alkalosis

Compensated respiratory acidosis

The pH is between 7.35 and 7.45, so the value is compensated. Because it is closer to 7.35, the value is considered acidotic.
To determine whether the acidosis is respiratory or metabolic, find the value that represents acidosis: CO2 > 45 mmHg

Normal Values:
pH is between 7.35 and 7.45
CO2 is between 35 and 45 mm Hg
HCO3 is between 22 and 26 mEq/L

Analyze the following arterial blood gas results.

pH 7.11
CO2 65
HCO3 17

-Uncompensated (mixed) respiratory/ metabolic acidosis
-Uncompensated metabolic alkalosis
-Compensated metabolic acidosis
-Uncompensated respiratory alkalosis

Uncompensated (mixed) respiratory/ metabolic acidosis

The pH is less than 7.35, so the value is uncompensated acidosis.
To determine whether the acidosis is respiratory or metabolic, find the value that represents acidosis: HCO3 <22 mEq/L and CO2 >45 mmHg, meaning the cause of the acidosis is both respiratory and metabolic in nature.

Normal Values:
pH is between 7.35 and 7.45
CO2 is between 35 and 45 mm Hg
HCO3 is between 22 and 26 mEq/L

Analyze the following arterial blood gas results.

pH 7.43
CO2 31
HCO3 20

-Uncomensated metabolic alkalosis
-Compensated respiratory acidosis
-Compensated respiratory alkalosis
-Uncompensated respirtory alkalosis

Compensated respiratory alkalosis

The pH is between 7.35 and 7.45 so the value is compensated. Because it's closer to 7.45, the value is considered alkalotic.
To determine whether the alkalosis is respiratory or metabolic, find the value that represents alkalosis: CO2 < 35 mmHg.

Normal Values:
pH is between 7.35 and 7.45
CO2 is between 35 and 45 mm Hg
HCO3 is between 22 and 26 mEq/L

Analyze the following arterial blood gas results.

pH 7.51
CO2 40
HCO3 35

-Uncompensated metabolic alkalosis
-Compensated respiratory acidosis
-Compensated metabolic acidosis
-Uncompensated respiratory alkalosis

Uncompensated metabolic alkalosis

The pH is greater than 7.45, so the value is Uncompensated.
To determine whether the alkalosis is respiratory or metabolic, find the value that represents alkalosis: HCO3 > 26 mEq/L.

Normal Values:
pH is between 7.35 and 7.45
CO2 is between 35 and 45 mm Hg
HCO3 is between 22 and 26 mEq/L

Analyze the following arterial blood gas results.

pH 7.17
CO2 55
HCO3 20

-Uncompensated metabolic alkalosis
-Uncompensated (mixed) respiratory/ metabolic acidosis
-Compensated metabolic acidosis
-Uncompensated respiratory alkalosis

Uncompensated (mixed) respiratory/ metabolic acidosis

The pH is less than 7.35, so the value is uncompensated acidosis.
To determine whether the acidosis is respiratory or metabolic, find the value that represent acidosis: HCO3 < 22 mEq/L and CO2 45 mmHg, meaning the cause of the acidosis is both respiratory and metabolic in nature.

Normal Values:
pH is between 7.35 and 7.45
CO2 is between 35 and 45 mm Hg
HCO3 is between 22 and 26 mEq/L

Analyze the following arterial blood gas results.

pH 7.38
CO2 38
HCO3 22

-Uncompensated metabolic alkalosis
-Compensated respiratory acidosis
-Compensated metabolic acidosis
-Normal

Normal

Normal Values:
pH is between 7.35 and 7.45
CO2 is between 35 and 45 mm Hg
HCO3 is between 22 and 26 mEq/L

Analyze the following arterial blood gas results.

pH 7.30
CO2 61
HCO3 25

-Uncompsated metabolic alkalosis
-Compensated respratory acidosis
-Compensated metabolic acidosis
-Uncompensated respiratory acidosis

Uncompensated respiratory acidosis

The pH is less than 7.35, so the value is Uncompensated.
To determine whether the acidosis is respiratory or metabolic, find the value that represents acidosis: CO2 >45 mmHg.

Normal Values:
pH is between 7.35 and 7.45
CO2 is between 35 and 45 mm Hg
HCO3 is between 22 and 26 mEq/L

A disadvantage of closed catheter suctioning of a tracheally ventilated patient would be:

-The extra weight of the inline tubing
-The patient does not receive oxygen during the procedure
-The cost is higher with a single-use catheter
-Closed catheter suctioning is cost-effective only if used sporadically

The extra weight of the inline tubing

The other answers are characteristics of open catheter suctioning.

When a closed system is used, its extra weight can increase tension on the catheter or tubing. This may cause the tracheostomy tube to move. Many manufacturers make inline tubing for both endotracheal tubes and tracheostomy tubes, so nurses must make certain they are using the correct tube for suctioning. Another problem with the inline catheters is the extra tubing that hangs out when the catheter is not in use. Patients may easily reach this tubing and extubate themselves or push the catheter down the airway and obstruct air flow.

The function of a stoma stent is:

-To provide the ability for the patient to speak
-To prevent aspiration
-To avoid translaryngeal intubation
-To keep the stoma tract open

To keep the stoma tract open

Stents can be manufactured in either straight or curved configuration, reflecting the differing nature of individuals' air passages. When the stent rests against the anterior wall of the trachea, it allows for freer passage of air and the patient can breathe spontaneously around the tube.

Which of the following statements is true regarding the use of a laryngeal mask airway (LMA)?

-Nurses routinely insert these airways
-There is a low risk of aspiration
-It is a temporary airway
-The vocal cords must be visualized

It is a temporary airway

The laryngeal mask airway (LMA) was intended for use as a temporary airway. It requires minimal training to insert, but it cannot be placed by RNs as a matter of course. The patient must be unconscious and/ or without gag reflex. The seal around the mask is a low-pressure seal, so it cannot be used on patients with high peak ventilator pressures. The LMA has a significant risk of aspiration as well as laryngospasm.

Advantages with the use of this airway are that it is blindly inserted into the hypopharynx, does not require visualization of the vocal cords, and does not traumatize the trachea. Patients will not have hoarseness or lose their voice altogether. At best, patients will complain of is a mild sore throat.

Which of the following statements about silicone or plastic tracheostomy tubes is true?

-The tubes offer a lower cost to the facility
-Wire-reinforced tubes cannot be used during MRI imaging
-A one-way speaking valve is easy to use
-Silicone hold up to repeated cleaning

Wire-reinforced tubes cannot be used during MRI imaging

The magnet in the MRI will attract the wires in the tube.
Silicone or plastic tubes cannot tolerate repeated cleaning.
Use of a one-way speaking valve is contraindicated when using a foam cuff, because the cuff may lie at an angle to the valve due to its orientation in the airway.
The cost of such tubes is actually higher to facilities because silicone and plastic tubes are difficult to keep clean and are labor intensive.

A complication of a tracheostomy tube would be that:

-It allows for right mainstem intubation
-It increases airway resistance
-It leaves a permanent scar
-The airway is less stable

It leaves a permanent scar

The tracheal tube provides a more stable airway, can be placed in a PCU setting, and decreases airway resistance. Because the tube is not positioned near the right mainstem bronchus, it will not facilitate intubation of the bronchus.

There are a large number of potential complications with the use of a tracheostomy tube such as:
Tracheal stenosis
Tracheal malacia (flaccidity of the tracheal
support cartilage )
Aspiration
Infection
Hemorrhage
Subcutaneous emphysema
Pneumothorax

Your patient has just been intubated. Documentation of the procedure usually would not include:

-The amount of time the intubator took to complete the task
-The depth of the tube
-The size of the tube
-CXR taken

The amount of time the intubator took to complete the task

Generally, the time it took for the intubator to complete the task is not documented, although if there was an unusual circumstance or a complication, it should be properly documented.
The depth of the tube is important to chart because it gives a reference point if any questions arise about tube migration.
The size of the tube is important to chart. The size of the tube may be too small or too large, so it would have to be adjusted to the next appropriate size.
A CXR is done to confirm tube placement; the time it is done should be documented.
Any medications given during the procedure should also be documented as to reason for administration, patient response, and follow-up such as vital signs and untoward reactions.

A complication/ contraindication of a nasal endotracheal tube could be:

-The patient cannot drink
-The tube offers easy access to the right mainstem bronchus
-The tube cannot be used for a patient with a cervical spine injury
-The tube may cause otitis

The tube may cause otitis

Because of the direct connection via the eustachian tube, infection in the ear is possible. If a cervial injury has been stabalized, it is certainly possible for a skilled intubator to place the tube. Additional complications associated with nasal endotracheal tubes include nasal bleeding, sinusitis, accidental esophageal intubation, vocal cord injuries, necrosis, cuff leak or failure, and obstruction.

Sinusitis, hospital acquired PNA nad ventilator acquired PNA pose many challenges for the PCU nurse. Sometimes a patient will be transferred to your unit with an already acquired infection, but then symptoms will become more pronounced. Which statement is true regarding these conditions:

-Good hand washing technique is effective for reducing VAP
-Sinusitis can be prevented by using a smaller-diameter endotracheal tube
-Nasogastric tubes are preferred to orogastric tubes
-Oral tubes have a greater incidence of sinusitis

Good hand washing technique is effective for reducing VAP

Sinusitis cannot be prevented simply by using a smaller-diameter ET. If anything, it will make the patient's work of breathing more difficult, though it will not necessarily contribute to an infectious process.
Orogastric tubes are preferable to nasogastric tubes whenever possible.
Good handwashing technique has been shown to be effective in reducing all types of hospital acquired infections.

Which of the following statements is true regarding the use of capnography to verify endotracheal tube placement:

-ETCO2 is a moderately reliable indicator of correct tube placement
-It is not necessary to auscultate lung sounds when this device is used
-It is a substitute for pulse oximetry
-Placement of the device can be difficult to learn initially

It is a substitute for pulse oximetry

ETCO2 is not a substitue for pulse oximetry. A pulse oximeter measure the availablity of sites on the hemoglobin molecule for oxygen transport verses the number of sites occupied. The ETCO2 indicates whether gas exchange is takin place at the cellular level. If CO2 is being given off, it will react with chemically treated paper in the detector. There is no excuse for not auscultating the patient's lungs to determine correct ETT placement. If the esophagus has been intubated, the ETCO2 may gave a false-positive reading if the patient has consumed a carbonated beverage within the past few hours.

Richard is a 61 year old male with a significant history of emphysema. He started smoking when he was 5 years old, and until this admission continued to smoke as many as 5 packs of cigarettes per day. In addition, he has uncontrolled diabetes and peripheral vascular disease. Three days ago, Richard had a major stroke when he was walking down the stairs. He suffered a broken pelvis and fractured his left radius. He has been comatose since his admission, with a flat line EEG study. His wife has agreed to discontinue ventilatory support. His doctor recommends that the patient receive morphine as a comfort measure during this process. Richard's wife has been informed that the morphine will make him more comfortable, but may decrease his ability to ventilate and, in fact, may hasten his demise. This type of ethical dilemma is known as:

-A null ethical principle
-Double effect
-Slippery slope
-Palliative principle

Double effect

Double effect is a common ethical dilemma. Here an action is justified as long as there is no intent to do harm. Neither the doctor nor the wife wants to hasten the patient's death, but they do want to make him more comfortable. It is the intent behind the use of the narcotic, rather than the use itself, that defines the double effect. At least some good is done with the outcome of the discussion and resolution of the dilemma.

A patient with a suspected diagnosis of active tuberculosis has been admitted to your care. The type of protective mask you should use is the:

-N95 respirator
-Particulate mask
-TB face mask
-Hood mask

N95 respirator

The N95 respirator is the primary mask to filter for TB particles. It should be test fit prior to use.

You watch a fellow nurse administer a TB skin test. She appears to place the needle too deep under the skin. As a nurse, you know that the test may be affected because:

-It may produce a false-positive
-Subcutaneous injection will nullify the result
-Necrosis will result
-Ulceration will result

Subcutaneous injection will nullify the result

The result will be nullified. False-negative results may occur if the patient has a bacterial infection, a live virus vaccination, renal failure, depleted sensitized T lymphocytes, or immunologic defects.

The volume of gas that is inspired and expired with normal effort is known as:

-Lung capacity
-Tidal volume
-Inspiratory verses expiratory ventilation
-Minute volume

Tidal volume

The tidal colume is the amount of gas inspired and expired with a normal breath. Think of it as the tide just coming in and going out with no extra effort. It is normally thought to be equivalent to approximately 10mL per kilogram of body weight.

Ian was driving his car through an intersection when he was T-boned by another car. Ian suffered a fractured pelvis and was stabalized in the ED, then transferred to the PCU to await surgical fixation of the fracture. When auscultating lung sounds, you hear what you believe to be bowel sounds in his chest. Ian states he has moderate shoulder pain on the left side, and he is mildly tachypneic. Ian will probably be diagnosed with:

-A fractured scapula
-Diaphragmatic rupture
-Hemothorax
-Bowel rupture

Diaphragmatic rupture

The patient's abdominal contents have probably entered the thoracic cavity secondary to a diaphragmatic tear. If air also enters the thoracic cavity, it will increase intrathoracic pressure and help to transmit sounds. usually, the left side of the diaphragm ruptures, and Ian was injured on the left side. The liver, because it is large, is believed to protect the right side of the diaphragm. A fractured pelvis usually also results in almost 50% increased probability of a ruptured diaphragm.

Ian was driving his car through an intersection when he was T-boned by another car. Ian suffered a fractured pelvis and was stabalized in the ED, then transferred to the PCU to await surgical fixation of the fracture. When auscultating lung sounds, you hear what you believe to be bowel sounds in his chest. Ian states he has moderate shoulder pain on the left side, and he is mildly tachypneic. The immediate priority for Ian's treatment is now:

-To ensure adequate oxygenation
-Immediate surgery
-Locate additional injuries
-Insert a chest tube

To ensure adequate oxygenation

Diaphragmatic rupture is a medical emergency. Maintenance of the airway and adequate oxygenation are always priorities. The adbominal contents' excursion into the thoracic cavity, along with the increase intrathoracic pressure, will cause hemodynamic compromise. Preload will be decreased, the patient will become tachycardic anddyspneic, have uneven diaphragmatic movement (on palpation), and may progress to shock. The shoulder pain on the side of the tear may become quite severe, and may further honder respiratory effort. Complications may include bowel obstruction and/ or strangulation. The patient may become so unstable that he must be stabalized before surgery can even be considered.

Which of the following conditions mandates the use of pain control?

-Hemothorax
-ARDS
-Flail chest
-Pulmonary contusion

Flail chest

A flail chest results when two or more adjacent ribs are broken in two or more places. The chest wall is unstable. Usually during inspiration, the chest wall moves outward with an increase in negative intrathoracic pressure. In cases of flail chest, the opposite movement of the chest wall is seen. This is know as "paradoxical" movement. Eventually the result will beatelectasis and alveolar collapse, with possible development of ARDS.

To adequately stabilize the fracture, neuromuscular blockade is sometimes used. The patient must be given pain medication and sedation. Also, pain management is a priority because the patient's work of breathing needs to be reduced.

Your patient has a confirmed flail chest. Which alteration in acid-base balance would you expect:

-Metabolic alkalosis
-Metabolic acidosis
-Respiratory acidosis
-Respiratory alkalosis

Respiratory acidosis

Flail chest is a very painful condition that limits respiratory effort because of the pain orfrom analgesia and sedation that may be required. The CO2 level will increase, PaO2 will decrease, and the pH will be below 7.35. The patient will develop respirtory acidosis.

One of the factors to be considered when assessing a patient for possible aspiration and chemical/ aspiration pneumonitis is:

-The possibility of using syrup of ipecac
-pH
-The type of infiltrates of CXR
-ABG results

pH

The pH of the aspirate is very important. If the aspirate is acidic, pulmonary edema develops almost immediately due to the collapse and breakdown of the alveoli, capillaries, and their interface. Atelectasis, possible intra-alveolar hemorrhage, and some intersititial edema lead to hypoxia. Other factors to identify are the type of matieral aspirated and the amount.

Syrup of ipecac is used for indigestions.
ABG results would be considered more of a diagnostic tools.

What is the proper location of chest tube for evcuation of a hemothorax:

-Second intercostal space, midclavicular line
-Second intercostal space, midaxillary line
--Fifth intercostal space, midclavicular line

Fifth intercostal space, midaxillary line

To evacuate fluids, the tube is placed low in the thoracic cavity and gravity is used to help clear the fluid. If a hemothorax is not completely removed, an infection may potentially occur, which can lead to empyema. When assessing a patient, it is a good idea to ask about the origin of small scars on the thoracic area. It may take years to cause a problem.

The hypoxemic type of respiratory failure is defined as:

-Increased dead air space
-PaO2 <60mmHg while person is at rest, at sea level, on room air
-ARDS
-COPD

PaO2 <60mmHg while person is at rest, at sea level, on room air

In this type of respiratory failure, PaCO2 may be either decreased or normal.

A ventilation/ perfusion mismatch (PNA, atelectasis) may occur as a result of an intrapulmonary shunt.

Alternatively, there may be increased alveolar dead space (shock, pulmonary embolism).

Pulmonary fibrosis may reduce diffusion capacity (COPD, ARDS).

A term for a patient who has been diagnosed with right ventricular hypertrophy caused by pulmonary hypertension caused by lung disease:

-Hyperplasia
-Thrombotic syndrome
-Cor pulmonale
-ARDS

Cor pulmonale

Cor pulmonale also results from right ventricular failure or dilation secondary to pulmonary hypertension caused by lung disease. The important distinction here is that the condition is not caused by any problem with the left ventricle. Acute cor pulmonale is usually the result of a massive pulmonary embolism that raises the PCR and causes increased preload and strain on the right heart.

Multiple organ dysfunction (MODS) may be directly caused by:

-Venous thrombosis
-Shunting
-Oral estrogen therapy
-Pulmonary embolism

Pulmonary embolism

If a pulmonary embolism decreases oxygen availability, the work of breathing increases, as does the respiratory rate. The thoracic respiratory muscles and the diaphragm will increase their oxygen demand, and respiratory muscle fatigue may result. Oxygen may be diverted to these muscles and deplete the oxygen and nutrient supples necessary for other vital organs. Thes organs may become inschemic and develop multiple organ dysfunction.

The other answers may all contribute to the formation of a pulmonary embolus.

Pulmonary embolism is actually considered a complication of deep venous thrombosis. To assess for DVT, which of the following signs should be assessed:

-Moses'
-Davis'
-Corrigan's
-Hamman's

Moses'

Traditionally, nurses were taught to assess Homan's sign: dorsiflexion of the ankle while bending the knee. If that action elicited pain, the patient had a problem with circulation and possibly a DVT. Moses' sign is elicited by pressing the calf toward the tibia, which may also elicit pain. These results are not exclusive to DVT, but may complement a diagnosis.

Your 50 year old patient was admitted with a complaint of a history of a cough that occured predominately in the morning for the past 4 years. The severity of the cough has increased over the past 3 days and wheezing is present, and the patient is dyspneic with mild exercise. The patient is probably suffering from:

-Asthma
-A pulmonary embolus
-COPD
-PNA

COPD

The most likely diagnosis is COPD. No information was given about a possible fever or lung sounds.

A 34-year old male is admitted to the PCU with a history of ETOH use and multiple previous admissions. He is now in severe end-stage hepatic failure. He is currently sedated and is in restraints for self protection. Vital signs are:

RR 16
BP 140/84
EKG ST at 112
SpO2 96%

The patient's wife visits and you inform her about the need for the restraints and the patient's need to sleep. She acknowledges this information and says she will sit quietly at the patient's bedside. About 5 minutes later, you find the patient extubated and very agitated. His wife states she released the restraints because she felt they were "too tight." Your priority in the care of this patient is:

-Immediate sedation for the agitation
-Remove the wife from the unit
-Notify the charge nurse
-Place the patient on a 40% mask and observe his response.

Place the patient on a 40% mask and observe his response

The airway is always a priority. After placing the mask and notifying the charge nurse, you have other options. If the patient is stable, you can notify the attending doctor and see if he wants to reintubate the patient or leave on the mask, change to another form of O2 delivery and/ or FiO2, draw ABGs or do nothing. If the patient's condition deterioriates, you may have the option of asking the ED doctor to intubate the patient.

The wife may have innocently believed she was doing good, but she may be a facilitator for her husband's drinking and behavior. She would certainly bear close watching if she is allowed to stay on the unit.

You are teaching your COPD patient about his treatment plan. Which of the following statements would indicate that the patient understands his disease and his treatment plan?

-"I should limit my fluid intake to 1 Liter per day."
-"I should use my Serevent inhaler as a rescue inhaler."
-"I should elevate and cross my legs while watching television."
-"I should avoid drinking or ingesting diary products."

"I should avoid drinking or ingesting diary products."

Dairy products may actually increase bronchospasm and may cause an increase in phlegm.

Fluid intake should be increased to approximately 3 L/day.

Serevent is a long-lasting inhaler and can take up to an hour to work.

Expected pharmacologic treatment for your patient with COPD would include:

-Sedatives
-Antihistamines
-Steroids
-Beta blockers

Steroids

Sedatives, antihistamines, and beta blockers are all to be avoided: they will diminish the respirtory drive and may cause bronchoconstriction.

You would expect to use steroids, mucolytics, and bronchodilators.

Where does the hypoxemic drive to breathe originate?

-Cerebellum
-Aortic and carotid arteries
-Hypothalamus
-Medulla

Aortic and carotid arteries

In the bifurcation of the internal and external carotid arteries, carotid bodies, and aortic bodies (in the carotid arch) are chemoreceptors. When the supply of oxygen decreases, stimulation of the aortic and/ or carotid bodies occur and, in turn, stimulates cortical activity. The result is adrenal glad secretions (epinephrine, norepinephren), tachycardia, tachypnea, increased respiratory rate, and increased blood pressure.

The functional residual capacity is:

-The amount of gas that can be forcefully exhaled after a maximum inspiration
-The amount of air left in the lungs after a normal expiration
-The amount of gas normally exhaled after a maximum inhalation
-The amount of gas left in the lungs after a maximum exhalation

The amount of air left in the lungs after a normal expiration

The formula for functional residual capacity is:
FCR=ERV (expired residual volume) + RV (residual volume)

The normal FRC in health lungs is approximately 2000 - 3000 mL.

Subcutaneous emphysema usually occurs in the area of the:

-Head
-Neck
-Thorax
-Abdomen

Thorax

Subcutaneous emphysema usually occurs in the thorax as a result of a pulmonary air leak. This air leak may be secondary to the patient receiving positive-pressure ventilation or from alveolar repture from a pneumothorax. The air travels along under the skin, where it may be easily palpated and feel like a crackling sensation. Patients who have chest tubes often have at least a small amount of subcutaneous emphysema at the tube insertion site. Sometimes the patient will feel pain when palpation is perfermed because the air tears the tissue. The free air must be reabsorbed, a process that may take several days.

Pulse oximetry has not been shown to be affected by:

-Dark skin
-Elevated bilirubin
-Dark nail polish
-Presence of hemoglobin

Dark skin

Bilirubin is not within the color spectrum that will interfere with pulse oximetry.

Dark nail polish, especially black, brown, blue, and green will interfere with light transmission and cause an artificial lowering of the SpO2.

Patients who have bruising under the nails may also have SpO2 values that are artificially decreased.

Pulse oximeters should never be used:

-To determine oxygen saturation values
-During a cardiac arrest
-As a determinant for predicting hemoglobin affinity for oxygen
-To help determine a patient's activity tolerance

During a cardiac arrest

During resuscitation, blood pressure and blood flow may vary. The pharmacologic effects of medications used during resuscitation (such as vasoactive drugs) will compromise the SpO2 values.

When setting alarm limits for a pulse oximeter, the oxygen saturation limit should be what percentage less than the patient's acceptable baseline:

-2%
-5%
-8%
-10%

5%

SpO2 values are not the same as PaO2 values. A slight drop in SpO2 is reflective of a major change in PaO2 values. That is why the alarm limits should never exceed 5% of the acceptable baseline. Also, heart rate alarms can be set in accordance with any EKG limits.

An SpO2 value of 95% correlates with which of the following PaO2 values:

-95 mmHg
-80 mmHg
-90 mmHg
-75 mmHg

80 mmHg

Pulse oximetry values do not directly correlate to PaO2. You must use ABGs to determine PaO2, the amount of oxygen available to the tissues. By comparison, SpO2 measures the number of hemoglobin binding sites that are occupied compared to the number of hemoglobin binding sites available.

What is the minimum number of staff required for use of the Vollman Prone Positioner (VPP) when providing manual pronation therapy for your patient?

-2
-3
-4
-5

3

With the Vollman Prone Positioner, one person is positioned on either side of the bed, and the third person at the head of the bed. The person at the head of the bed is responsible for maintaining cervial stability, the stability and positioning of the endotracheal tube, ventilator tubing, intravenous lines, and any monitoring cables.

Which of the following conditions would not be considered a contraindication for the use of pronation therapy?

-Pregnancy
-Weight of 160 Kg
-Unstable pelvis
-Open abdomen

Open abdomen

If the abdomen is open, the area may be covered with synthetic material and an abdominal binder used to help secure the abdomen.

Additional contraindications would include an unstable spine, an unstable chest wall, an open chest, a bifurcated endotracheal tube, and blood pressures <90 mmHg in a patient who is receiving vasoactive medications.

Nursing actions that should be performed prior to initiating pronation therapy would include:

-Securing the EKG leads on the anterior chest with tape
-Noting the amount of all drainage for colostomies and ileostomies
-Utilizing capnography monitoring
-Documenting existing drainage on any wound dressings

Utilizing capnography monitoring

Adding a capnographic device will help assure appropriate positioning of the endotracheal tube while turning the patient and when the patient is in the prone position.
All EKG leads should be removed from the anterior chest wall and all wound dressings should be changed prior to placing the patient in the prone position.
All colostomy and ileostomy bags should be emptied because the patient's weight may cause the bags to rupture.

To prevent complications with chest tube drainage systems, the suction level should not be higher than:

- (-)20 cm/H2O
- (-)30 cm/H2O
- (-)40 cm/H2O
- (-)50 cm/H2O

(-)40 cm/H2O

Maintaining suction levels higher than -40 cm H2O may cause reexpansion pulmonary edema, pleural air leaks, and lung tissue entrapment. The lung may not be able to expand properly.

Which of the following statements is true regarding chest tube drainage systems?

-Drainage of frank blood in amounts >100mL/h is not significant
-Drainage tubing should be placed horizontally on the bed and down to the collection chamber
-All drainage tubing should be dependent to the insertion site
-Chest tube drainage from a mediastinal tube should not bubble in the water seal chamber

Chest tube drainage from a mediastinal tube should not bubble in the water seal chamber

If a medistinal chest tube is in place, bubbling in the water seal chamber may indicate a communication between the medistinal space and the pleural space. The doctor should be notified immediately. However, some sporadic bubbling will occur when suction is first turned on because fluid must displace air in the collection chamber.

Chest tube tubing that is dependent or coiled will allow for the accumulation of drainage, and this obstruction may increase pressure in the lung.

Cayden is a 36 year old patient originally admitted for a fractured femur and to rule out coronary contusion following a skiing accident. While you are giving Cayden his discharge teaching, he suddenly complains of pain in his left chest. He immediately becomes tachypneic and tachycardic. As you lay Cayden back down in the bed, you note asymmetrical chest wall excursion and neck vein distention. He has absent breath sounds on the left side and his heart sounds are muffled. Cayden rapidly becomes dyspneic and cyanotic. Cayden's condition is likely due to:

-Tension pneumothorax
-Cardiac tamponade
-Pulmonary embolism
-Esophageal rupture

Tension pneumothorax

The patient is exhibiting the classic symptoms of a tension pneumothorax. Air has leaked into the pleural space and, because the thorax is closed, increasing pressure has caused the lung to collapse Tension pneumothorax is a medical emergency.

Cayden is a 36 year old patient originally admitted for a fractured femur and to rule out coronary contusion following a skiing accident. While you are giving Cayden his discharge teaching, he suddenly complains of pain in his left chest. He immediately becomes tachypneic and tachycardic. As you lay Cayden back down in the bed, you note asymmetrical chest wall excursion and neck vein distention. He has absent breath sounds on the left side and his heart sounds are muffled. Cayden rapidly becomes dyspneic and cyanotic. Cayden requires an immediate needle decompression for a left tension pneumothorax. The needle will be placed in:

-The second intercostal space at the left midclavicular line
-The third intercostal space at the left midaxillary line
-The forth intercostal space at the left midaxillary line
-The fifth intercostal space at the left midclavicular line

The second intercostal space at the left midclavicular line

The needle is actually placed just above the third rib at the midclavicular line on the affected side. This placement, using the edge of the bone to guide the needle, should lessen the possibility of damaging the artery, vein, and nerve that are located just below each rib. Additional complications could include cellulitis, localized hematoma, pleural infection, and pneumothorax if the patient did not have a tension pneumothorax.

Which of the following would be considered a relative compliation for performing a thoracentesis:

-Spenomegaly
-Coagulation disorder
-Previous pneumonectomy
-Pleural fluid protein to serum protein ratio greater than 0.5 g/dL

Pleural fluid protein to serum protein ratio greater than 0.5 g/dL

A high pleural fluid to serum protein ratio will cause a fluid shift and result in an effusion. This is a reason for performing a thoracentesis.

Contraindications for performing a thoracentesis include coagulation disorders or patients receiving anticoagulants, abnormal anatomy (normal landmarks cannot be clearly identified), and splenomegaly. In patients with a pneumonectomy, a thoracentesis may damage the remaining lung or drastically change intrapleural pressure, possible collapse of the lung.

Physiologic PEEP is:

-The same as plateau pressure
-The same as static pressure
-The positive pressure remaining in the alveoli
-A factor that decreases the work of breathing

The positive pressure remaining in the alveoli

Physiologic PEEP is the amount of positive pressure that remains in the alveoli after exhalation and keeps the alveoli from totally collapsing.
Auto-PEEP occurs when the patient is mechanically ventilated and an amount of PEEP remains in the alveoli. Auto-PEEP is in addition to physiologic PEEP.
Causes of Auto-PEEP include use of a small-diameter endotracheal tube, bronchospasm, water in the ventilator tubing, high minute ventilation, and high respiratory rates. Patients actually have increased work of breathing because, to initiate a breath on the ventilator, they have to overcome the set sensitivity and the amount of Auto-PEEP. Corrective measures include use of a large-diameter endotracheal tube, slower respiratory rates, emptying the water from the ventilatory tubing, use of sedatives and/ or narcotics, and adjustment of the ventilator to shorten inspiratory time and lengthen exhalation time.

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