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Chapter 23: Disorders of Ventilation
Terms in this set (34)
Which of the following clients is at risk for developing a preventable disorder related to prolonged immobility?
a. A middle-aged adult male diagnosed with bronchitis related to chronic smoking
b. A young adult female diagnosed with sarcoidosis requiring corticosteroids to return her to remission
c. A postsurgical client who is refusing to get out of bed and walk and will not wear those "uncomfortable elastic stocking"
d. A sleep apnea client related to a history of smoking who utilizes a C-PAP machine every night at bedtime to maintain airway
A postsurgical client who is refusing to get out of bed and walk and will not wear those "uncomfortable elastic stocking"
A lack of mobility can result in secondary atelectasis (through incomplete lung expansion) and pulmonary embolism (from deep vein thrombosis). This is not the case with the other listed disorders of ventilation and gas exchange.
Prolonged immobility is implicated in the development of which of the following disorders?
a. Bronchitis and bronchiectasis
b. Sarcoidosis and idiopathic pulmonary fibrosis
c. Atelectasis and pulmonary embolism
d. Pulmonary hypertension and cor pulmonale
Atelectasis and pulmonary embolism
Lack of mobility can result in secondary atelectasis (through incomplete lung expansion) and pulmonary embolism (from deep-vein thrombosis). This is not the case with the other listed disorders of ventilation and gas exchange.
Oxygen has been prescribed for a client with chronic obstructive pulmonary disease (COPD). Select the most appropriate treatment for the client.
a. 1 to 2 L/min via nasal cannula
b. 4 to 6 L/min via nonrebreather mask
c. 10 L/min via nasal cannula
d. 5 L/min via venture mask
1 to 2 L/min via nasal cannula
The goal of oxygen delivery for a client with COPD is to keep the PO2 at about 60 mm Hg or less, which can be accomplished with delivery of 1 to 2 L/min of oxygen via nasal cannula, which results in a PO2 at 55 to 65 mm Hg. All the other options would increase the PO2 above 60 mm Hg, which tends to depress the hypoxic stimulus for ventilation and often leads to hypoventilation and carbon dioxide retention.
Acute-onset bronchial asthma causes wheezing and breathlessness as a result of which of the following?
a. Airway inflammation
b. Alveolar collapse
c. Compression atelectasis
d. Pulmonary hypertension
Bronchial asthma represents a reversible form of obstructive airway disease caused by narrowing of airways due to bronchospasms, inflammation, and increased airway secretions; this inflammatory process produces recurrent episodes of airway obstruction, characterized by wheezing, breathlessness, chest tightness, and cough. Vascular flow through the lungs is unaffected by the airway inflammation and bronchospasms. Hyperinflated alveoli are characteristic of the emphysema type of obstructive pulmonary disease. Compression atelectasis is associated with high external pressure that blocks lung expansion.
A patient diagnosed with congestive heart failure has an arterial blood oxygen level (PaO2) of 89%. Which of the following terms should the nurse use to document a reduced oxygenation of arterial blood?
Hypoxemia refers to a reduction in arterial blood O2 levels, which is considered a PaO2 less than 95 mm Hg. Hypoxemia can result from an inadequate amount of O2 in the air, a disorder of the respiratory system, dysfunction of the neurologic system, or alterations in circulatory function.
A car accident client is admitted with a chest tube following pneumothorax. He also has an elevated blood alcohol level. When the nurse enters his room, she notes the client is dyspneic, short of breath, and holding his chest tube in his hand. When the nurse pulls the linens back, she finds a "sucking" chest wound. After calling a "code blue," the next priority intervention would be to:
a. Place the client's meal napkin over the wound
b. Observe and wait for the code blue team to bring equipment
c. Try to calm the patient down by maintaining therapeutic communication
d. Apply a Vaseline gauze (airtight) dressing over the insertion site
Apply a Vaseline gauze (airtight) dressing over the insertion site
The client has a medical emergency. Sucking chest wounds, which allow air to pass in and out of the chest cavity, should be treated by promptly covering the area with an airtight covering. Chest tubes are inserted as soon as possible. The other interventions will not help minimize the amount of air entering the pleural space.
Unilateral chest pain associated with respiratory movements is usually described as which of the following?
Pleuritis is usually unilateral and tends to be localized to the lower and lateral part of the chest; pain worsens with chest movements, such as deep breathing and coughing that accentuate pressure changes in the pleural cavity and increase movement of the inflamed or injured pleural surfaces. Musculoskeletal pain usually is bilateral and may occur as the result of frequent, forceful coughing. The pain associated with irritation of the bronchi usually is substernal and dull. Myocardial pain usually is located in the substernal area and is not affected by respiratory movements.
A client with primary lung disease has developed right heart failure. The health care provider would document this as:
a. Adult respiratory distress syndrome
b. Primary hypertension
c. Cor pulmonale
d. Cardiac tamponade
The term cor pulmonale refers to right heart failure resulting from primary lung disease or pulmonary hypertension. The increased pressures and work result in hypertrophy and eventual failure of the right ventricle. The manifestations of cor pulmonale include the signs and symptoms of the primary lung disease and the signs of right-sided heart failure. Primary hypertension is elevated blood pressure of unknown cause. Cardiac tamponade is pressure on the heart that occurs when blood or fluid builds up in the space.
A child is brought to the emergency department struggling to breathe with a prolonged bronchospasm and severe hypoxemia. Assessment revealed the use of accessory muscles, a weak cough, audible wheezing sound, moist skin, and tachycardia. Which of the following is the most likely diagnosis?
a Severe asthma attack
b. Chronic obstructive pulmonary disease
c. Pulmonary embolism
d. Cystic fibrosis
Severe asthma attack
Severe asthma attacks are accompanied by use of the accessory muscles, distant breath sounds due to air trapping, and loud wheezing. As the condition progresses, fatigue develops, the skin becomes moist, and anxiety and apprehension are obvious. Sensations of shortness of breath may be severe, and often the person is able to speak only one or two words before taking a breath. At the point at which airflow is markedly decreased, breath sounds become inaudible with diminished wheezing, and the cough becomes ineffective despite being repetitive and hacking. This point often marks the onset of respiratory failure.
A patient with a 25-year history of smoking is diagnosed with emphysema. Physical assessment reveals an increased anterior-posterior chest diameter. Which of the following terms should the nurse use to document this finding?
a. Barrel chest
b. Pink puffer
c. Blue bloater
An increased anterior-posterior chest diameter is referred to as a barrel chest.
A patient is diagnosed with pulmonary embolism. Which of the following symptoms would most likely be present?
a. Chest pain and dyspnea
b. Shallow respirations and wheezing
c. Left arm pain and diaphoresis
d. Cough and crackles
Chest pain and dyspnea
The manifestations of pulmonary embolism depend on the size and location of the obstruction. Chest pain, dyspnea, and increased respiratory rate are the most frequent signs and symptoms of pulmonary embolism.
The nurse is caring for a client diagnosed with pneumonia. The client's arterial blood gas results identify decreased level oxygen in the arterial blood and a decreased in the partial pressure of oxygen. The nurse would interpret this as:
Hypoxemia refers to a reduction in PO2 of the arterial blood. Hypoxemia can result from an inadequate amount of O2 in the air, disease of the respiratory system, dysfunction of the neurologic system, or alterations in circulatory function. Hypercapnia is an increase in the carbon dioxide content of the arterial blood. Atelectasis is collapse of a segment of the lung due to airway obstruction.
A patient recently had surgery for a hip fracture. Which of the following nursing interventions would be most effective for preventing pulmonary emboli in this patient?
a. Prevention of the development of a deep vein thrombosis
b. Use of oxygen and incentive spirometer following surgery
c. Monitor hematocrit and hemoglobin levels
d. Encourage increase fluid intake
Prevention of the development of a deep vein thrombosis
Almost all pulmonary emboli are thrombi that arise from deep-vein thrombosis in the lower and upper extremities. The presence of thrombosis in the deep veins of the legs or pelvis often is unsuspected until an embolism occurs.
Common results of respiratory failure are hypoxemia and which of the following?
d. Pulmonary emboli
The common result of respiratory failure is hypoxemia, or low level of oxygen in the blood, and hypercapnia, or excess carbon dioxide in the blood. Acute hypoxia incites sympathetic nervous system responses such as tachycardia. Hypercapnia refers to an increase in carbon dioxide levels. The manifestations of hypercapnia consist of those associated with the vasodilation of blood vessels, including those in the brain and depression of the central nervous system (e.g., carbon dioxide narcosis). Thrombus formation in pulmonary vessels is unrelated to ventilation failure.
An asthmatic patient comes to the emergency department very anxious due to increasing shortness of breath. Physical assessment reveals tachypnea, and an arterial blood gas shows decreased carbon dioxide levels and hypoxemia. Which of the following is the most likely cause?
Nonpharmacological management of asthma includes relaxation techniques and controlled breathing, which often help to allay the panic and anxiety that aggravate breathing difficulties. The hyperventilation that often accompanies anxiety and panic is known to act as an asthmatic trigger.
A client with a history of heart failure and COPD (caused by 60 pack/year smoking) presents to the clinic with the following complaints: auscultation of breath sounds reveal absent/diminished breath sounds in the right lower lobe. Which other manifestations lead the health care provider to suspect the client may have developed atelectasis? Select all that apply.
a. Respiratory rate—32; pulse rate—122 beats/minute.
b. "Having a hard time catching my breath."
c. "Seems like I'm not making much water (decreased urine production)."
d. Using accessory muscles to help him breathe.
e. Copious amounts of thick, green sputum.
Respiratory rate—32; pulse rate—122 beats/minute.
"Having a hard time catching my breath."
Using accessory muscles to help him breathe.
Atelectasis is caused most commonly by airway obstruction rather than a vascular obstruction. The clinical manifestations of atelectasis include tachypnea (respiratory rate of 32), tachycardia (pulse rate of 122) dyspnea (hard time catching breath), cyanosis, signs of hypoxemia, diminished chest expansion, absence of breath sounds, and intercostal retractions (use of accessory muscles). Both chest expansion and breath sounds are decreased on the affected side. There may be intercostal retraction (pulling in of the intercostal spaces) over the involved area during inspiration. Urine production is not related to atelectasis. Copious green sputum is associated with infection.
A patient arrives in the ED after an automobile accident. Which of the following clinical manifestations leads the nurse to suspect a pneumothorax? Select all that apply.
a. Respiratory rate 34.
b. Asymmetrical chest movements, esp. on inspiration.
c. Diminished breath sounds over painful chest area.
d. Pulse oximetry 98%.
e. ABG pH level of 7.38
Respiratory rate 34.
Asymmetrical chest movements, esp. on inspiration.
Diminished breath sounds over painful chest area.
Manifestations of pneumothorax include increase respiratory rate, dyspnea, asymmetrical movements of chest wall, esp. during inspiration, hyperresonant sound on percussion and decreased or absent breath sounds over area of pneumothorax. The pulse oximetry reading is normal. ABG pH level of 7.38 is a normal finding.
With acute respiratory distress syndrome (ARDS), a client progressively increases his work of breathing. The physiological principle behind this respiratory distress is related to:
a. Increases in left atrial pressure causing thickening of the lining of the pulmonary arteries
b. The elevation of pulmonary venous pressure
c. Structural abnormalities of pulmonary vessels with proliferation of the vessel intima
d. The stiffening of the lung, making it more difficult to inflate
The stiffening of the lung, making it more difficult to inflate
As the disease (ARDS) progresses, the work of breathing becomes greatly increased as the lung stiffens and becomes more difficult to inflate. There is increased intrapulmonary shunting of blood, impaired gas exchange, and hypoxemia despite high supplemental oxygen therapy. With pulmonary hypertension, there are continued increases in left atrial pressure, which can lead to medial hypertrophy and intimal thickening of the small pulmonary arteries, causing sustained hypertension. Pulmonary hypertension also causes an elevation of pulmonary venous pressure.
A client has sudden severe dyspnea, fear, asymmetrical chest movement and decreased lung sounds on the right side. Which intervention is most appropriate?
a. Administer Morphine Sulfate (morphine) to reduce pain and increase contractility.
b. Assist to high-Fowler's position and prepare for chest tube insertion.
c. Position HOB at 45 degrees and prepare for intubation to improve respiratory status.
d. Position limbs above heart for venous return and give dobutamine (Dobutrex) IV.
Assist to high-Fowler's position and prepare for chest tube insertion.
Spontaneous pneumothorax can occur in healthy people and tends to occur most often in tall boys and young men between the ages of 10 and 30 years. It is treated with insertion of chest tubes to reinflate the affected lung.
A teenaged cystic fibrosis client presents to the clinic. The health care provider (HCP) knows that cystic fibrosis (CF) causes severe chronic respiratory disease in children. In addition, the HCP should also focus his or her assessment on which of the other body systems affected by CF?
d. Central nervous system
Cystic fibrosis (CF) is manifested by pancreatic exocrine deficiency and elevation of sodium chloride in the sweat. Cystic fibrosis (CF) is an inherited disorder involving fluid secretion by the exocrine glands in the epithelial lining of the respiratory, gastrointestinal, and reproductive tracts. Excessive loss of sodium in the sweat predisposes young children to salt depletion episodes. Respiratory manifestations are caused by an accumulation of viscid mucus in the bronchi, impaired mucociliary clearance, lung infections, bronchiectasis, and dilatation. The renal, cardiac, and CNS are usually not involved with CF manifestation.
A motor vehicle accident has resulted in critical injury for the driver of the car. The driver has hit the steering wheel with his chest and fractured his sternum and some ribs. Which of the following manifestations would lead the staff to suspect the driver has developed a tension pneumothorax? Select all that apply.
a. Audible friction rub over the affected lung
b. Mediastinal shift of the trachea toward one side
c. Marked peripheral edema in lower limbs and ascites
d. Atrial fibrillation noted on ECG printout
e. Subcutaneous emphysema palpated in the upper chest/neck region
Mediastinal shift of the trachea toward one side
Subcutaneous emphysema palpated in the upper chest/neck region
With tension pneumothorax, the structures in the mediastinal space shift toward the opposite side of the chest. There may be distention of the neck veins, subcutaneous emphysema (i.e., presence of air in the subcutaneous tissues of the chest and neck), and clinical signs of shock. Pneumothoraces do not typically cause a friction rub or dysrhythmias. Marked peripheral edema is associated with right-sided heart failure.
Which client is showing signs of chronic hypoxemia? A client who is
a. lying in bed talking on the phone using complete sentences.
b. diaphoretic and breathless after walking in the hall.
c. restless, has clubbed fingers, and frequently drops items.
d. sitting up in bed with blue lips expressing sudden feelings of doom.
restless, has clubbed fingers, and frequently drops items.
Signs of chronic hypoxemia include clubbing of the fingers, polycythemia, pulmonary vasoconstriction, restless or agitated behavior, incoordination, and reduced mental function with impaired judgment. Cyanosis indicates an excessive concentration of deoxygenated hemoglobin. A sudden feeling of doom is a characteristic sign of pulmonary embolus.
As a result of hypoxemia and polycythemia, persons with chronic obstructive bronchitis are prone to:
a. Breakdown of elastin
b. Left-sided heart failure
c. Pulmonary hypertension
d. Expiratory airway collapse
Hypoxemia causes reflex vasoconstriction of the pulmonary vessels and further impairment of gas exchange in the lung. Hypoxemia also stimulates red blood cell production, causing polycythemia. As a result, persons with chronic obstructive bronchitis may develop pulmonary hypertension and right-sided heart failure. With breakdown and loss of lung elasticity and hyperinflation of the lungs with emphysema, the airways often collapse during expiration.
A client with hypercapnia needs to increase calorie intake without increasing work of breathing. What menu selection is the best choice?
a. Grilled salmon, baked potato, and bread pudding
b. Mixed green salad, corn muffin, and iced tea
c. Chicken salad, refried beans, and guacamole
d. Pasta with meat sauce, garlic bread, and carrots
Chicken salad, refried beans, and guacamole
Dietary fat metabolism produces the least amount of carbon dioxide (CO2) in relation to the amount of oxygen used, and supplies 9 calories per gram. Proteins produce more CO2 and supply 4 calories per gram. Carbohydrate metabolism produces the most CO2 and supplies 4 calories per gram. So the client should eat more fats and proteins while reducing carbohydrate intake.
What description is characteristic of the pathology of chronic bronchitis?
a. Airways are obstructed by mucus, causing hypoxemia.
b.Airway expansion is restricted by external pressures, leading to hypercapnia.
c. Airways constrict and become narrower, causing wheezing and cyanosis.
d. Airways become stiff and resist expansion, leading to hypoxemia
Airways are obstructed by mucus, causing hypoxemia.
Chronic bronchitis is a progressive obstructive lung disorder in which the airways are blocked by mucus or inflammation. Asthma is a disorder of lung constriction that causes wheezing. Interstitial lung diseases are characterized by restriction of lung function due to loss of elasticity in collagen and connective tissues in the interstitium of the alveolar walls. The general pattern of lung dysfunction includes reduced diffusing capacity of the lung, diminished lung volume, and some degree of hypoxemia.
Which of the following statements best captures the etiology of the acute response phase of extrinsic (atopic) asthma?
a. IgG production is heightened as a consequence of exposure to an allergen.
b. Airway remodeling results in airflow limitations.
c. Epithelial injury and edema occur along with changes in mucociliary function.
d. Chemical mediators are released from pre-sensitized mast cells.
Chemical mediators are released from pre-sensitized mast cells.
The acute response phase of extrinsic asthma is characterized by the release of chemical mediators from mast cells that have been sensitized. Epithelial injury and edema as well as airway remodeling are not associated with the acute phase, and IgE, not IgG, is primarily involved in asthma.
A client with cystic fibrosis reports recent weight loss without fever or cough. What interventions will the nurse implement to promote health for the client? Select all that apply.
a. Increase protein intake
b. Increase pancreatic enzymes
c. Increase chest percussion
d. Increase aerobic activity
e. Increase mucolytic use
Increase protein intake
Increase pancreatic enzymes
Cystic fibrosis is a genetic disorder that produces abnormal functioning in the epithelial cell chloride channels. This leads to thick, viscous secretions that block the lung passages and the pancreatic ducts resulting in chronic lung infections, and malabsorption and malnutrition. Treatment for CF is intended to maintain maximum function while minimizing secondary organ damage. Antibiotic therapy, chest percussion and drainage, and adequate hydration are appropriate for respiratory symptoms. Pancreatic enzymes, vitamin and mineral supplements, increased protein intake, and insulin may be needed with pancreatic involvement.
Upon admission to the ICU, a patient with a history of cor pulmonale will likely be exhibiting which of the following clinical manifestations of right heart failure? Select all that apply.
a. Fine crackles throughout both lung fields.
b. +4 pitting edema in lower extremities.
c. Expectorating copious amounts of frothy, pink sputum.
d. Jugular vein distension.
e. Altered level of consciousness.
+4 pitting edema in lower extremities.
Jugular vein distension.
Altered level of consciousness.
Signs of right-sided HF include venous congestion (jugular vein distension), peripheral edema (+4 pitting edema in feet), shortness of breath and productive cough. Altered level of consciousness may occur as the result of carbon dioxide retention. Fine crackles in all lung fields and frothy, pink sputum are common in left-sided HF.
Which of the following diagnoses will present the highest risk for hypercapnic/hypoxemic respiratory failure?
b. Severe pneumonia
d. Pulmonary edema
A patient diagnosed with drug overdose has the greatest risk of developing hypercapnic/hypoxemic respiratory failure. Severe pneumonia and atelectasis presents a risk for simple hypoxemic respiratory failure, whereasimpaired diffusion is a possible outcome for pulmonary edema.
Which factors increase the risk that a client will develop chronic obstructive pulmonary disease (COPD)? Select all that apply.
a. History of tobacco use
c. Diabetes mellitus
d. History of myocardial infarction
e. History of asthma
History of tobacco use
History of asthma
Smoking is the primary cause of chronic obstructive pulmonary disease (COPD). Additional causes are a hereditary deficiency of alpha1-antitrypsin and asthma. Obesity may contribute to respiratory distress, but is not a cause of COPD. Myocardial infarction (MI) and diabetes mellitus are contributing factors to heart disease, not COPD.
Which manifestations are most common in clients with COPD that is predominantly chronic bronchitis? Select all that apply.
a. Peripheral edema
c. Increased A-P diameter
d. Increased mucus secretion
Increased mucus secretion
In chronic bronchitis, there is an increase in mucus production, cyanosis, and often fluid retention associated with right heart failure. Emphysema is noted for its loss of lung elasticity and enlargement of the distal air spaces. This leads to hyperresonance, decreased breath sounds, and an increase in the A-P chest diameter, commonly called barrel chest. Clients with emphysema tend to take short frequent breaths and exhale through pursed lips.
Which of the following is the most common cause of hypercapnia?
a. Alterations in respiratory rate
b. Alterations in carbon dioxide production
c. Disturbances in gas exchange in the lungs
d. Abnormalities in the function of the chest wall
Alterations in respiratory rate
Hypercapnia refers to an increase in carbon dioxide levels. In the clinical setting, four factors contribute to hypercapnia: alterations in carbon dioxide production, disturbance in the gas exchange function of the lungs, abnormalities in function of the chest wall and respiratory muscles, and changes in neural control of respiration. Alterations in respiratory function or the rate decrease minute volume, which is the most common cause of hypercapnia.
Which manifestations are most common in clients with COPD that is predominantly emphysema? Select all that apply.
a. peripheral edema
c. increased A-P diameter
d. increased mucus secretion cyanosis
increased A-P diameter
Emphysema is noted for its loss of lung elasticity and enlargement of the distal air spaces. This leads to hyperresonance, decreased breath sounds, and an increase in the A-P chest diameter, commonly called barrel chest. Clients with emphysema tend to take short frequent breaths and exhale through pursed lips. In chronic bronchitis, there is an increase in mucus production, cyanosis, and often fluid retention associated with right heart failure.
Which are the earliest manifestations that a client is developing hypoxemia? Select all that apply.
d. Personality changes
Early signs of hypoxemia are subtle and may include increased heart rate, peripheral vasoconstriction leading to a mild rise in blood pressure, diaphoresis, and a slight decrease in visual acuity and mental performance. Cyanosis indicates an excessive concentration of deoxygenated hemoglobin.
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