Upgrade to remove ads
Care of Critically Ill Patients with Respiratory Problems
Terms in this set (86)
Which are the risk factors for pulmonary embolism (PE) and DVT?
-Cancer (particularly lung or prostate)
What is the most common site of origin for a clot to occur, causing a PE?
Deep veins of the legs and pelvis
What is the most common cause of embolism?
Which conditions define respiratory failure?
-Combination of ventilatory and oxygenation failure
A patient in the hospital being treated for a PE is receiving a continuous infusion of heparin. When the nurse comes to take vital signs, the patient has blood on the front of his chest and nose, and is holding a tissue saturated with blood to his nose. What is the first priority action the nurse must take?
Stop the heparin IV infusion
The nurse's young neighbor who smokes is going on an overseas flight. The neighbor knows he is at risk for DVT and PE, and asks the nurse for advice. What does the nurse suggest?
Drink water and get up every hour for at least 5 minutes during the flight
The nurse is caring for several postoperative patients at risk for developing PE> Which interventions does the nurse use to help prevent the development of PE in these patients?
-Start passive and active range-of-motion exercises for the extremities
-Ambulate postoperative patients soon after surgery
-Use anti embolism devices postoperatively
-Administer drugs to prevent episodes of Valsalva maneuver
The nurse suspect a patient has a PE and notifies the provider who ordered an arterial blood gas. The provider is en route to the facility. The nurse anticipates and prepares the patient for which additional diagnostic test?
The provider orders heparin therapy for a patient with relatively small PE. The patient states, "I didn't tell the doctor my complete medical history". Which condition may affect the providers decision to immediately start heparin therapy?
Recent cerebral hemorrhage
A patient with a PE asks for an explanation of heparin therapy. What is the nurse's best response?
It increases the time it takes for blood to clot, therefore preventing further clotting and improving blood flow
A patient is being treated with heparin therapy for a PE. The patient has the potential for bleeding with the administration of heparin. What does the nurse monitor in relation to the heparin therapy?
PTT values for greater than 2.5 times the control and/or the patient for bleeding
Acute respiratory failure is classified by which critical values of PaCO2?
- 52 mm Hg
- < 60 mm Hg
- > 50 mm Hg with a pH values of < 7.3
Upon diagnoses of a PE, the nurse expects to perform which therapeutic intervention for the patient?
Parenteral anticoagulant therapy
The nurse is caring fora patients with a postoperative complication of PE. The patients has been receiving treatment for several days. Which factors are indicators of adequate perfusion in the patient?
-Pulse oximetry of 95%
-Absence of pallor or cyanosis
-Mental status at patient's baseline
Which are extrapulomary causes of ventilatory failure?
-Use of opioid analgesics
The nurse is caring for several postoperative patients with high risk for a PE. All of these patients have preexisting chronic respiratory problems. What is a unique assessment finding for a clot in the lung?
Sudden dry cough
The nurse is caring for several patients at risk for DVT and PE. Which condition causes the patient to be a candidate for a placement of a vena cava filter?
Recurrent bleeding while receiving anticoagulants
A patient with a massive PE has hypotension and shock, and is receiving IV crystalloids. However, the patient's cardiac output is not improving. The nurse anticipates an order for which drug?
An older adult patient on anticoagulation therapy for a PE is somewhat confused and requires assistance with activities of daily living (ADLs). Which instruction specific to this therapy does the nurse give to the UAP?
Use a lift sheet when moving or turning the patient in bed
A patient with a PE is receiving anticoagulant therapy. Which assessment related to the therapy does the nurse perform?
Examine skin every 2 hours for evidence of bleeding
What does the nurse monitor for in a patient with a PE?
-Rapid heart rate
-Crackles in the lung fields
After receiving IV heparin anticoagulant therapy, patient's are generally not discharged from the hospital without a prescription and instructions for which drug?
A patient is following up on a postoperative complication of PE. The patient must have blood drawn to determine the therapeutic range for coumadin. Which lab test determines this therapeutic range?
PT and INR
The nurse is reviewing lab results for a patient with a new-onset PE. What is the INR therapeutic range?
A patient demonstrates chest pain, dyspnea, dry cough, and change in the level of consciousness. The nurse suspects PE and notifies the HCP who orders ABG. In the early stage of a PE, what would ABG results probably indicate?
A patient recently received anticoagulant therapy for complications of PE after knee surgery. The patient is now in a rehab facility and is receiving warfarin (Coumadin). What is the nursing responsibility related to coumadin?
Teaching the patient about foods high in vitamin K
Ventilatory failure is there result of what processes?
-Defect in there respiratory control center of the brain
-Physical problem of the lungs
-Poor function of the diaphragm
-Physical problem of the chest wall
What conditions are related to acute respiratory distress syndrome (ARDS)?
-Lung fluid increases
-A systemic inflammatory response occurs
-Lung volume is decreased
The nurse is reviewing the ABG for a patient. The latest ABGs show pH 7.48, HCO3 23 mEq/L, PaCO2 25 mm Hg, PaO2 98 mm Hg. What is the correct interpretation of these lab findings?
Acute respiratory alkalosis and hyperventilation
The nurse is caring for a patient with acute hypoxemia. Which nursing intervention are best for the care of this patient?
-Prescribed meter-dose inhalers
A patient reports pain with inspiration after falling off a skateboard. The provider makes the diagnosis of rib fracture. The nurse prepares to do patient teaching for which treatment?
Coughing and deep-breathing
The nurse is assessing a patient who sustained significant chest trauma during a motor vehicle accident. What significant assessment finding suggests tension pneumothorax?
Tracheal deviation to the unaffected side
The nurse is assessing a patient with a hemothoraz. When the nurse performs percussion of the chest on the affected side, what type of sound is expected?
On arrive the the ED, the patient develops extreme respiratory distress and the provider identifies a tension pneumothorax. The nurse prepares to assist with which initial urgent procedure?
Insertion of a large-bore needle into the second intercostal space on the affected side
The nurse is performing patient teaching for a patient who will be taking anticoagulants at home. What does the nurse include in the instructions?
-Do not take aspirin or any aspirin containing products
-Do not participate in activities that will cause bumps, scratches, or scrapes
-Eat warm, cool, or cold foods to avoid burning your mouth
-If you must blow your nose, do so gently without blocking either nasal passage
Which patient has the greatest risk for developing ARDS?
74-year-old who aspirates a tube feeding
Which assessment finding is considered an early sign of ARDS?
Intercostal and suprasternal retractions
A patient with which condition is a potential candidate for autotransfusion, should the need arise?
A patient sustained a chest injury resulting from a motor vehicle accident. The patient is asymptomatic at first, but slowly develops decreased breath sounds, crackles, wheezing, and blood in the sputum. The mechanism of injury and physical findings are consistent with what condition?
A patient is admitted after a near-drowning and develops ARDS, which is confirmed by the provider. The nurse prepares equipment for which treatment?
Mechanical ventilation and endotracheal tube
A 19-year-old patient was seen in the ED after a motorcycle accident for multiple rib fractures that resulted in free-floating ribs, paradoxical breathing, and inadequate oxygenation. What is this condition called?
The high-pressure alarm of a patient's mechanical ventilator goes off. What are the potential causes for this?
-Patient is fighting the ventilator
-Patient is coughing
The low-pressure alarm of a patient's mechanical ventilator goes off. What are potential causes for this?
-Cuff leak in the endotracheal or tracheostomy tube
-Patient has stopped breathing
-Leak in the circuit
A patient with ARDS is currently in the exudative management stage. What is the focus of the nursing assessment?
Note early changes in dyspnea and tachypnea
The nurse is caring for a patient at risk of pulmonary contusion. Why is this a potentially lethal chest injury?
Respiratory failure develops over time
A patient has been successfully intubated by the provider, and the nurse and respiratory therapist are securing the tube in place. What does the nurse include in the documentation regarding the intubation procedure?
-Presence of bilateral and equal breath sounds
-Level of the tube
-Changes in vital signs during the procedure
-Presence (or absence) of dysrhythmias
-Placement verification by end-tidal carbon dioxide levels
The nurse is assisting with an emergency intubation for a patient in severe respiratory distress. Although the provider is experienced, the procedure is difficult because the patient has severe kyphosis. At what point does the nurse intervene?
First intubation attempt last longer than 30 seconds
A patient in the ED required emergency intubation for status asthmatics. Immediately after the insertion of an ET tube, what is the most accurate method for the nurse and/or provider to use to verify correct placement?
Check end-tidal CO2 level
The nurse is caring for several patients on the medical-surgical unit who are experiencing acute respiratory problems. Which conditions may eventually require a patient to be intubated?
-Trouble maintaining a patent airway because of mucosal swelling
-Copious secretions and lacking muscular strength to cough
-Increasing fatigue because of the work of breathing
The nurse receives report on a patient with ARDS who has been intubated for 6 days and has progressive hypoxemia that responds poorly to high levels of oxygen. This patient is in which phase of ARDS case management?
A postoperative patient reports sudden onset of shortness of breath and pleuritic chest pain. Assessment findings include diaphoresis, hypotension, crackles in the left lower lobe, and pulse oximetry of 85%. What does the nurse suspect has occurred with this patient?
The nurse hears in shift report that a patient has been agitated and pulling at the ET. Soft restraints have recently been ordered and placed, but the patient continues to move his head and chew at the tube. What does the nurse do to ensure proper placement of the ET tube?
Mark the tube where it touches the patient's teeth
The nurse is caring for patient on a mechanical ventilator. What does the nurse monitor to assess for the most likely cardiac problem associated with this therapy?
Check blood pressure
A patient in the critical care unit requires an emergency ET intubation. The nurse immediately obtains and prepares which supplies to perform this procedure?
-Resuscitation Ambu bag
-Source for 100% oxygen
-Airway equipment box (e.g. laryngoscope)
A patient on a ventilator is biting and chewing at the ET tube. Which nursing intervention is used for ET management?
Insert an oral airway
The nurse is performing a check of the ventilator equipment. What is included during the equipment check?
Note the prescribed and actual settings
The nursing student is assisting in the care of a critically ill patient on a ventilator. Which action by the student nurse requires intervention by the supervising nurse?
Deflates the cuff on the ET tube to check placement
A patient has a history of COPD and had to be intubated for respiratory failure. That patient is currently on a mechanical ventilator. The nurse obtains an order for which type of dietary therapy for this patient?
High-fat nutritional supplement
The nursing student is assisting in the care of a patient on a mechanical ventilator. Which action by the student contributes to the prevention of ventilator-assisted pneumonia?
Performs oral care every 2 hours
The nurse is caring for a patient on a mechanical ventilator. During the shift, the nurse hears the patient talking to himself. What does the nurse do next?
Check the inflation of the pilot ballon
The nurse notices that a patient has a gradual increase in peak inspiratory pressure over the last several days. What is the best nursing intervention for this patient?
Assess for a reason such as ARDS or pneumonia
A patient is intubated and has mechanical ventilation with positive end-expiratory pressure (PEEP). Because this patient is at risk for a tension pneumothorax, what is the nurse's priority action?
Assess lung sounds every 30 to 60 minutes
The nurse is caring for a patient on a mechanical ventilator. Which assessment does nurse perform for this patient?
-Observe the patient's mouth around the tube for pressure ulcers
-Auscultate the lungs for crackles, wheezing, equal breath sounds, and decreased or absent breath sounds
-Assess the placement of the ET
-Check to be sure alarms are set
-Observe the patient's need for tracheal, oral, or nasal suctioning every 2 hours
What are the characteristics of a mechanical ventilator that is pressure-cycled?
-Preset inspiration and expiration rate is programmed with possible variation of tidal volume and pressure
-It pushes air into the lungs until a preset airway pressure is reached
-Tidal volumes and inspiratory times are varied
What are the characteristics of a mechanical ventilator that is time-cycled?
-It needs an artificial airway such as a tracheostomy or ET
-It is positive-pressure ventilator
-Its tidal volumes are variable
-Preset inspiration and expiration rate can be set with possible variation of tidal volume
What are the characteristics of a noninvasive pressure support (bi-pap)?
-It provides noninvasive pressure support ventilation by nasal mask or face mask
-It is most often used for patients with sleep apnea
-It may be used for patients with respiratory muscle fatigue
Which statement about a microprocessor ventilator is true?
A computer monitors ventilatory functions, alarms, and patient condition
The nurse hears an alarm go off on mechanical ventilator that signals the ventilator is not able to give the patient a breath. What are the possible reasons that would make this alarm go off?
-The tubing has become disconnected
-The patient has become disconnected from the ventilator
-The patient needs to be suctioned
A patient with a tracheostomy who is on a mechanical ventilator is beginning to take spontaneous breaths at his own rate and tidal volume between set ventilator breaths. Which mode is the ventilator on?
SIMV (synchronized intermittent ventilation)
A patient who is on a mechanical ventilator needs a set volume and set rate delivered because the patient is not able to do the work of breathing. To what mode must the ventilator be set?
The provider instructs the nurse to watch for and report signs and symptoms of improvement so the patient can be weaned from the ventilator. Which assessment finding indicates the patient is ready to be weaned?
Patient is receiving only 1-2 mechanical ventilator breaths per minute
An older adult patient arrives in the ED after falling off a roof. The nurse observes "sucking inward" of loos chest area during inspiration and a "puffing out" of the same area during expiration. ABG results show severe hypoxemia and hypercarbia. Which procedure does the nurse prepare for?
The charge nurse in the intensive care unit is reviewing the patient census and caseload to identify staffing needs and potential transfers. Which patient might take the longest time to wean from a ventilator?
54-year-old man with metazoic colon cancer who has been intubated for 6 days
A patient is being extubated and the nurse has emergency equipment at the bed side. Which intervention is implemented during extubation?
Instruct the patient to cough after tube is removed
The nurse is caring for a patient who was recently extubated. What is an expected assessment finding for this patient?
The patient is to be extubated. What action does the nurse perform first?
Explain the procedure
Which patients on mechanical ventilators are at high risk for barotrauma?
-Patient with ARDS
-Patient with underlying chronic airflow limitation
-Patient on PEEP
The nurse is caring for a patient who has just been extubated. What intervention does the nurse use in caring for this patient?
-Assess the ventilatory pattern for manifestations of respiratory distress
-Instruct the patient to take deep breaths every half hour
-Encourage use of an incentive spirometer every 2 hours
-Advice the patient to limit speaking right after extubation
The nurse is assessing a patient who was extubated several hours ago. Which patient finding warrants notification of the Rapid Response Team?
Inability to expectorate secretions
A patient is admitted to the trauma unit following a front-end motor vehicle collision. The patient is currently asymptomatic, but the provider advises the nurse that the patient patient has a high risk for pulmonary contusion. What does the nurse carefully monitor for?
Decreased breath sounds
Which finding might delay learning a patient from mechanical ventilation support?
Arterial PO2 = 70 mm Hg on a 40% FiO2
A patient in respiratory failure is diagnosed with a flail chest. After the patient is intubated, which treatment does the nurse expect to be implemented?
A patient in a motor vehicle accident was unrestrained and appears to have hit in the front dashboard. The patient has severe respiratory distress, inspiratory stridor, and extensive subcutaneous emphysema. The ED physician identifies tracheobronchial trauma. Which procedure does the nurse immediately prepare for?
What causes the potential cardiac problems that can result form mechanical ventilation?
Positive pressure increases in the chest
What is the cardiac problem that can occur from mechanical ventilation?
Which clinical manifestation can occur from cardiac problems due to mechanical ventilation?
-Decreased cardiac output
THIS SET IS OFTEN IN FOLDERS WITH...
Chapter 32 Care of Critically Ill Patients with Re…
Iggy, Ch 45, Care of Critically Ill Patients with…
Chapter 8 Concepts of Emergency and Trauma Nursing
Ch 31 - Care of Patients with Infectious Respirato…
YOU MIGHT ALSO LIKE...
Chapter 32: Acute respiratory disorders and pulmon…
NUR 216 EXAM #2
OTHER SETS BY THIS CREATOR
Aging and End of Life Exam 2
Care of Critically Ill Patients with Neurologic Pr…
Care of Patients with HIV Disease and other Immune…
Care of Patients with Burns
OTHER QUIZLET SETS
Theology LAP 8 Study Guide
BO: Chapter 11 Pharmacology Study Guide
Audiology Week 1
Anatomy & Physiology II--Mod.5