Chapter 8: Oxygenating the Machine: The Respiratory System Summary

Introduction

• Respiration is the process that facilitates the exchange of gases between living organisms and their environment.
• It occurs in three processes:
  • Breathing: It involves the exchange of air between the lungs and the environment (into and out of the lugs).
  • Exchanging gases: It occurs between the blood, body cells, and alveolar cells. It occurs in two ways:
    • Pulmonary respiration
    • Systemic respiration
  • Cellular respiration: It involves the utilization of oxygen by the body cells in catabolism to produce energy.

Terms in the respiratory system

Adult breathing rate: 12 to 20 times in a minute.

Hypoxia: A low oxygen amount in expired air.

Lung capacity: Residual air plus the vital capacity.

Mediastinum: The region between the lungs and the diaphragm.

Minimal air: the total lung air volume when fully collapsed.

Residual air: The air retained in the lungs after forced expiration.

Tidal air: Total inspired and expired air volume at resting state.

Vital capacity: Total air volume from a forceful expiration.

What happens during breathing in and out

• Hemoglobin in red blood cells moves carbon dioxide and oxygen within the body.
• Hemoglobin loosely binds to oxygen to form oxyhemoglobin and transports it throughout the body.
• Hemoglobin picks carbon dioxide after releasing oxygen to allow for expiration to occur.
• Carbohemoglobin is the hemoglobin and carbon dioxide complex.

The nose

• Every nasal cavity has the respiratory region and the olfactory region.
• The olfactory region: It is located in the upper nasal cavity region.
  • They contain a network of fine filaments composed of special nerves for the sense of smell.
• The respiratory region: it is lined with a pseudostratified, columnar ciliated epithelial mucous membrane.
  • It contains the mucous and sebaceous glands.
  • The secretions from these glands are protective, warm, moisten, and filter inhaled air.
• The nasal cavity also has sinuses which reduce the weight of the skull and function as resonators for the voice. Types of sinuses include the following:
  • Frontal sinus found in the front bone marrow.
  • Maxillary sinus found in the maxillae.
  • Sphenoid sinuses and Ethmoid found in the sphenoid and ethmoid bones.

 Roles of the nasal cavity

• Drainage of mucous secretions from sinuses.
• Lachrymal secretion drainage from the eyes.
• It warms, moistens, and filters inhaled air.

The throat

• It contains the larynx and the pharynx.
• Pharynx: It is a 5 inch long fibromuscular oval sac.
  • The region where the pharynx and the esophagus connect is the narrowest part of the digestive system
  • The pharynx is connected to the ear via the Eustachian tube.
• The larynx: It connects the trachea with the pharynx.
  • It is composed of 9 cartilages and is commonly known as Adam’s apple.
  • It appears like a dorsally flattened triangular box with cylindrical and narrow sides directed towards the base.
  • The mucous membrane that lines the larynx also extends to the trachea.
• Single larynx cartilages include the cricoid, thyroid, and epiglottis.
• The paired larynx cartilages include the corniculate, arytenoids, and the cuneiforms.

The lungs

The trachea comes after the pharynx and larynx.

The trachea contains C- shaped rings containing hyaline cartilage along with a fibrous connective tissue that maintains it open.

The trachea branches into two bronchi separated by the cariba.

The right primary bronchi are wider and shorter than the left primary bronchi.

Every primary bronchi branch into secondary bronchi and each branch goes into each lobe of the lungs.

The secondary branches then separated into tertiary bronchi.

Tertiary bronchi divide to form bronchioles.

Every bronchiole is connected to the alveolar sac(atrium, alveolar sac).

Alveoli have small capillaries that pick up oxygen and release carbon dioxide.

The right lung is larger, wider, and has 3 lobes.

The left lung is longer, narrower, and has 2 lobes.

Each lobe further divides into lobules.

REVISION

Compliance
Measure of the force required to expand or inflate the lungs.

Crackles
Soft, High-Pitched, discontinuous popping sounds during INSPIRATION caused by delayed reopening of the airways.

Diffusion
Exchange of gas molecules from areas of high concentration to areas of low concentration.

Fremitus
Vibrations of speech felt as tremors of chest wall during palpation.

Hypoxemia
Decrease in arterial oxygen tension in the blood.

Hypoxia
Decrease in oxygen supply to the tissues and cells.

Rhonchi
Low-pitched wheezing or snoring sound associated with partial airway obstruction, heard on chest auscultation.

Stridor
Harsh, High-Pitched sound heard on inspiration, usually without need of stethoscope, secondary to upper airway obstruction.

Tidal Volume
Volume of air inspired and expired with each breath during normal breathing.

Ventilation
Movement of air in and out of the airways.

Wheezes
Continuous musical sounds associated with airway narrowing or partial obstruction.

Acute Respiratory Distress Syndrome
ARDS
A severe form of acute lung injury.
*Sudden & Progressive Pulmonary Edema
*Increasing Bilateral Infiltrates on chest x-ray
*Hypoxemia unrelieved by Oxygen
*Absence of an elevated Left Lung atrial pressure.
*Reduced Lung Compliance

Risk Factors for ARDS
Aspiration
Drug Ingestion/Overdose
DIC, Massive blood transfusions, Cardiopulmonary Bypass
Prolonged inhalation (Oxygen, Smoke, Corrosive stuff)
Localized Infection (Bacterial, Fungal, Viral Pneumonia)
Metabolic Disorders (Pancreatitis, Uremia)
Shock
Trauma (Lung, Multiple Fractures, Head Injury)
Major Surgery
Fat or Air Embolism
Systemic Sepsis

What is the major cause of death with ARDS?
Non-pulmonary Multiple-system Organ Failure, often with Sepsis

ARDS occurs as a result of __?
Diffuse alveolar damage.

What time frame does ARDS typically develop over?
Acute Event (4 – 48hours)

Acute phase of ARDS
Rapid onset of severe Dyspnea that usually occurs 12 to 48 hours after the initiating event.
Arterial Hypoxemia that does not response to oxygen.

Assessment and Diagnostic Findings with ARDS
Intercostal Retractions/ Crackles
Plasma BNP
Echocardiography
Pulmonary Artery Catheterization (Definitive)

Early signs of lack of oxygen
Tachypnea
Tachycardia
Restlessness
Pale skin and mucous membranes
Elevated Blood Pressure
Symptoms of Respiratory Distress (Accessory muscles, Nasal flaring, Tracheal tugging, and Adventitious lung sounds)

Late signs of lack of oxygen
Confusion and Stupor
Cyanotic skin and mucous membranes
Bradypnea
Bradycardia
Hypotension
Cardiac dysrhythmias

Oxygen toxicity can result from what?
High concentrations of oxygen (above 50%)
Long durations of oxygen therapy (more than 24-48hr)
Client’s degree of lung disease

S/S of Oxygen Toxicity
Non-Productive Cough
Substernal pain
Nasal stuffiness
N/V
Fatigue
Headache
Sore Throat Hypoventilation

How is fluid retention a complication of Mechanical Ventilation?
Fluid retention in clients who are receiving mechanical ventilation is due to:
Decreased Cardiac Output
Activation of Renin-Angiotensin-Aldosterone system
Ventilator humidification

Nasal Cannula
24%-44% Oxygen
1 – 6 L/min
*Humidification is necessary for 4+ L/min

Simple Face Mask
40%-60% Oxygen
1 – 6 L/min (Minimum 5 L/min to ensure flushing of CO2)
Short-Term

Partial Rebreather Mask
60%-75% Oxygen
6 – 11 L/min
*Use with caution for clients at high risk of aspiration or airway obstruction

Non-Rebreather Mask
80%-95% Oxygen
10 – 15 L/min

Venturi Mask
24%-55% Oxygen
2 – 10 L/min via different sized adaptors
Expensive

For a client on Mechanical Ventilation, Breath Sounds should be monitored every ____hr, and Blood Pressure should be monitored every ____hr.
2-4hr; 1 hour

Ventilatory failure
Due to a mechanical abnormality of the lungs or chest wall, impaired muscle function (the diaphragm), or a malfunction in the respiratory control center of the brain.

Oxygenation failure
Can result from a lack of perfusion to the pulmonary capillary bed (pulmonary embolism) or a condition that alters the gas exchange medium (pulmonary edema, pneumonia).

Acute Respiratory Failure shows what type of ABGs?
PaO2 <60 SaO2 <90% PaCO2 >50
pH <7.30

What indicators are present with ARDS?
Dyspnea
Pulmonary Edema (Non-Cardiogenic)
Reduced Lung Compliance
Pulmonary patchy infiltrates
Severe hypoxemia despite 100% Oxygen

Benzodiazepines
Lorazepam (Ativan)
Midazolam (Versed)
*Reduces anxiety and resistance to ventilation and decreases O2 consumption.
–Use cautiously in conjunction with opioid narcotics.

General Anesthesia
Propofol (Diprivan)
*Used to induce and maintain anesthesia
–Contraindicated for clients with hyperlipidemia and egg allergies.
–Only for intubated and ventilated
–Monitor ECG, BP, and Sedation levels
–Monitor for Hypotension

Assist Control Ventilation (AC)
-Pre-set Ventilator and Tidal Volume
-Client can initiate breaths, however, the ventilator takes over and delivers a pre-set tidal volume.
**Barotrauma
-Hyperventilation can result in Respiratory Alkalosis
-Client may require increased sedation to decrease RR

Synchronized Intermittent Mandatory Ventilation (SIMV)
-Pre-set Ventilator Rate and Tidal Volume
-For client-initiated breaths, tidal volume depends on the client’s efforts.
-The vent senses the patient’s own breaths and synchronizes
-Self-initiated breaths have no support
-After 30-45 minutes, ABGs are tested, and settings are adjusted.
-Used as a regular mode of ventilation and as a weaning mode.
-Can increase the work of breathing and respiratory muscle fatigue.

Pressure Support Ventilation (PSV)
-Weaning Mode
-Allows patient to do the work of breathing with backup
-Provides constant pressure during inspiration
ALWAYS USED IN CONJUNCTION WITH CPAP!!!
-Patient will not be moved from this until the patient is at 30% Oxygen and can follow commands.
-Client controls rate and tidal volume
-Decreases the work of breathing and promotes respiratory muscle conditioning.
-No ventilator breaths are delivered

Positive and Expiratory Pressure (PEEP)
-Positive pressure applied at the end of expiration to increase functional residual capacity and improve oxygenation by OPENING COLLAPSED ALVEOLI!!
-PEEP must be used in conjunction with AC or SIMV.
-PEEP decreases CO and can cause volutrauma and increased ICP.

Volutrauma
Trauma to lung tissue caused by Tidal Volumes that are too HIGH!!!

Continuous Positive Airway Pressure (CPAP)
Positive pressure supplied during spontaneous breaths.
No ventilator breaths are delivered unless they are in conjunction with SIMV
RISKS include:
Volutrauma
Decreased CO
Increased ICP
CPAP can be invasive or non-invasive
**Obstructive Sleep Apnea

Bilevel Positive Airway Pressure (BiPAP)
Positive pressure delivered during spontaneous breaths.
Different pressures are delivered for inspiration and expiration
No spontaneous breaths are delivered
BiPAP is non-invasive

Pressure-Cycled Positive Pressure
Air is forced in until a pre-set pressure is reached.
Machine stops, expiration occurs passively
SHORT TERM (PACU)

Time-Cycled Positive Pressure
Controls inspiration, can change I/E Ratio (Norm 2:1)
NEONATES AND CHILDREN

Volume-Cycled Positive Pressure
MOST COMMON
Forces volume into the lungs until a pre-set volume is reached.

Volume Alarms
LOW PRESSURE
Low exhaled volume due to a disconnection
Cuff leak
Tube displacement

Pressure Alarms
HIGH PRESSURE
Excess secretions
Client biting the tubing
Kinks in the tubing
Client coughing
Pulmonary edema
Bronchospasm
Pneumothorax

S/S of Weaning Intolerance
RR >30 or <8/min
BP/HR changes more than 20% baseline
SaO2 <90%
Dysrhythmias, Elevated ST
Decrease in TV
Labored Respirations
Restlessness, Anxiety, Decreased LOC

Which modes of ventilation can increase conditioning of the respiratory muscles by requiring the client to generate the force to take spontaneous breaths?
SIMV (Synchronized)
CPAP
PSV (Pressure Support)

What does Pressure Support Ventilation do?
Provides pressure on spontaneous ventilation to decrease the work of breathing.

Neuromuscular Blocking Agents
Vecuronium (Norcuron)
Facilitate ventilation and decreases oxygen consumption
Often used with painful ventilatory modes
**Given only to intubated/ventilated clients
–Monitor ECG, BP, Muscle strength
–Antidotes: methylsulfate (Prostigmin) & atropine sulfate (Atropair)

What does PEEP do?
Exerts pressure at the end of expiration to prevent alveolar collapse and improve gas exchange!

A client who develops acute respiratory distress syndrome (ARDS) is exhibiting hypoxemia that is unresponsive to oxygen therapy. In explaining the client’s condition to the family, the nurse would incorporate which of the following concepts?

a. The individual has difficulty expelling air trapped in the alveoli.
b. There is excess surfactant production by the alveoli.
c. Thick secretions block the airways.
d. Blood is shunted past alveoli with no ventilation.
d. One of the primary alterations occurring with ARDS is the collapse of alveoli, causing loss of ventilation in these areas. Perfusion may be normal, but gas exchange is impaired because of inadequate ventilation. Surfactant production decreases with ARDS, a factor that impairs adequate gas exchange. Air does not become trapped in hyperinflated alveoli in ARDS; instead, alveoli collapse.

In a client with respiratory distress, which finding by the nurse most manifests a worsening clinical state?

a. Cyanosis
b. Increased respiratory rate
c. Agitation
d. Tachycardia
a. Cyanosis

A 12-year-old is being treated for acute respiratory distress syndrome. Which assessment finding would be indicative of the nursing diagnosis of impaired gas exchange?

a. Bicarbonate level of 38 mEq/L
b. Heart rate of 100 bpm
c. Respiratory rate of 60/min
d. Oxygen saturation of 62%
d. Normal levels of oxygen saturation are 95-100%. The client with an O2 level of 62% is not exchanging gases. Heart rate increase is a sign of many disorders and by itself does not signify impaired gas exchange. A respiratory rate of 60 signifies respiratory distress but does not imply impaired gas exchange. Bicarbonate levels are an indication of kidney function.

The client with an acute lung injury has developed acute respiratory distress syndrome (ARDS). The nurse monitors the client carefully for which complication of ARDS?

a. Hearing impairment
b. Multiorgan system failure
c. Vision loss
d. Blood clots
b. The client with ARDS is at risk for developing multiorgan system failure related to ineffective tissue oxygenation including kidney failure, liver failure, gastrointestinal failure, central nervous system failure, and cardiovascular failure. Blood clots, vision loss, and hearing impairment are not hallmarks of ARDS or multiorgan system failure.

The nurse is monitoring a client who is mechanically ventilated due to acute respiratory distress syndrome (ARDS). The nurse determines that the client has met the outcome for reduced anxiety when the client: (Select all that apply.)

Is able to rest.
Keeps eyes open.
Has a relaxed facial expression.
Fights the ventilator.
Thrashes the legs.

1. Is able to rest.
2. Has a relaxed facial expression

The nurse is working with the physician to wean a client with acute respiratory distress syndrome (ARDS) from the ventilator. Which of the following interventions will the nurse avoid during the process of weaning?

a. Antibiotic administration
b. Daily hygiene care
c. Administration of sedatives
d. Suctioning the client
c. The client with ARDS who is being weaned from the ventilator should not be given sedatives that depress respiration. When the client is being weaned, the nurse optimizes respiratory function to promote successful weaning. Daily hygiene, antibiotics, and suctioning are all appropriate for the weaning client.

The nurse is caring for a client who is being discharged after recovering from acute respiratory distress syndrome (ARDS). The family asks if the client is out of danger and if normal activities can be resumed. Which of the following will the nurse explain to the client and family?

a. “The client is out of danger and can resume normal activities.”
b. “The client will be ready for normal routines in about a year.”
c. “The client will never recover fully.”
d. “Maximal respiratory function should return in six months.”
d. Full recovery from ARDS takes about six months, so the client is taught measures to prevent further lung trauma. The client is not out of danger at discharge. One year is much longer than the typical recovery time. Some clients may never fully recover, but a six-month time period is generally correct.

The nurse caring for a client undergoing mechanical ventilation for acute respiratory distress syndrome (ARDS) plans which of the following interventions to help maintain effective alveolar ventilation?

a. Maintains ordered oxygen concentration
b. Increases the tidal volume on the ventilator
c. Keeps the client in a supine position
d. Performs endotracheal suctioning as indicated
d. Patent airways are necessary to maintain effective alveolar ventilation and gas exchange. Keeping the client in a supine position does not promote a patent airway. If the airway is full of secretions, increasing tidal volume and maintaining oxygen concentration are not helpful in keeping the airway patent.

SIRS
T >100.4 or <96.8 F HR >90
RR >20
PCO2 <32 WBC >12 or <4

Sepsis
SIRS + Infection

Severe Sepsis
SIRS + Sepsis + Organ Failure

Septic Shock
Severe Sepsis + Persistent Hypotension despite fluids!

Compensatory Stage of Shock
SNS causes vasoconstriction, increased HR, increased heart contractility
This maintains BP, CO
Body shunts blood from skin, kidneys, GI tract, resulting in cool, clammy skin, hypoactive bowel sounds, decreased urine output
Perfusion of tissues is inadequate
Acidosis occurs from anaerobic metabolism
Respiratory rate increases due to acidosis, may cause compensatory respiratory alkalosis.
Confusion may occur

Progressive Stage of Shock
Mechanisms that regulate BP can no longer compensate, BP and MAP decrease
MAP Average pressure at which blood moves through the vasculature > 65 mmHg for cells to receive 02 & nutrients
SBP + 2 (DBP) / 3 120/80 – 120 + 160/3 so 280/3 = 93.3333
Vasoconstriction continues further compromising cellular perfusion
Mental status further deteriorates from decreased cerebral perfusion, hypoxia
Lungs begin to fail, decreased pulmonary blood flow causes further hypoxemia, carbon dioxide levels increase, alveoli collapse, pulmonary edema occurs
Inadequate perfusion of heart leads to dysrhythmias, ischemia
As MAP falls below 70, GFR cannot be maintained
Acute renal failure may occur
Liver function, GI function, hematological function all affected
DIC (Disseminated Intravascular Coagulation) may occur as cause or complication of shock

Irreversible Stage of Shock
At this point, organ damage so severe that patient does not respond to treatment, cannot survive
BP remains low
Renal, liver function fail
Anaerobic metabolism worsens acidosis
Multiple organ dysfunction progresses to complete organ failure
Judgment that shock is irreversible is only made in retrospect

Superior Vena Cava
8-10

Right Atrium
0-8

Right Ventricle
15-25/
0-8

Pulmonary Artery
15-25/
8-15

Left Atrium
4-12

Left Ventricle
110-130/
4-12

Aorta
110-130/
70-90

Pulmonary Artery Wedge Pressure
4-12

Systemic Vascular Resistance
800-1200

Pulmonary Vascular Resistance
20-130

CVP
2-8

Cardiac Output
4-8

The nurse identifies it is MOST important to observe for hyperventilation in a patient receiving which mode of mechanical ventilation?

a) control ventilation (CV)
b) assist-control ventilation (AC)
c) synchronous intermittent mandatory ventilation
d) continuous positive airway pressure (CPAP)

(Kaplan Resp Set B 1/30)
b) tidal volume and ventilatory rate are pre-set; oxygen is delivered without patient effort, but if patient does inspire it will respond to that effort; if patient respiratory rate increases spontaneously, such as because of pain, anxiety or neurological causes, the machine continues to deliver the pre-set tidal volume with each breath; hyperventilation and respiratory alkalosis result; cause of hyperventilation must be corrected; machine sensitivity may be adjusted

(Kaplan Resp Set B 1/30)

A patient is admitted to the hospital with a diagnosis of acute right upper lobe pneumonia. The patient has a history of chronic bronchitis and type 1 diabetes. Which symptom would the nurse expect to see?

a) moist, cool skin
b) rust-colored sputum
c) bradycardia
d) decreased respiratory rate

(Kaplan Resp Set B 2/30)
b) purulent, blood-tinged or rust-colored sputum due to inflammation; increased respirations, dyspnea, pleuritic pain; treatment includes antibiotics, chest physiotherapy, cough and deep breathe every two hours; encourage fluids; assess breath sounds

(Kaplan Resp Set B 2/30)

The nurse cares for a patient after rhinosplasty and observes bright red blood on the external dressing. Which action should the nurse take FIRST?

a) return the patient to the operating room
b) contact the physician
c) examine the patient’s throat
d) perform nasopharyngeal suctioning

(Kaplan Resp Set B 3/30)
c) assessment is the first step of the nursing process; nurse should observe for bloody drainage in the throat; hemorrhage is an emergency situation that requires the physician to repack internal dressings

(Kaplan Resp Set B 3/30)

The nurse cares for a client diagnosed wit tuberculosis. The client asks, “Why do I have to take vitamin B6 (pyroxidine)?” What explanation does the nurse provide?

a) promote the absorption of isoniazid (an antibiotic)
b) prevent neuritis
c) alleviate gastrointestinal symptoms
d) prevent kidney damage

(Kaplan Resp Set B 4/30)
b) neuritis is a potential complication of isoniazid treatment; vitamin B6 (pyridoxine) is given along with the isoniazid to help prevent neuritis

(Kaplan Resp Set B 4/30)

A patient with a chest tube asks the nurse about the bubbling he sees in the water seal chamber of his drainage equipment. Which response by the nurse is the MOST appropriate?

a) “it’s supposed to do that.”
b) “it shows your lung has not yet re-expanded.”
c) “why don’t you ask your doctor?”
d) “what do you think it means?”

(Kaplan Resp Set B 5/30)
b) this response provides a true, factual answer

(Kaplan Resp Set B 5/30)

Blood gas results on a patient with emphysema indicate severe hypoxia. Oxygen therapy is ordered. Which method of oxygen administration will MOST likely be used?

a) face mask with reservoir
b) face mask without reservoir
c) nasal cannula
d) venturi mask

(Kaplan Resp Set 6/30)
d) Venturi masks provide oxygen at specified percentages, which is how oxygen should be administered to patients with COPD or emphysema; keep tubing free of kinks

(Kaplan Resp Set 6/30)

The nurse cares for the client needing a tracheostomy. The client’s daughter asks the nurse, “Why does my father need a tracheostomy?” The nurse understands that which is the primary reason for performing a tracheostomy?

a) promotes pulmonary function
b) improves breathing capabilities
c) prevents respiratory infections
d) decreases respiratory tract secretions

(Kaplan Resp Set 7/30)
b) the main purpose of a tracheostomy is to provide and maintain an airway, which permits the removal of tracheobronchial secretions when the patient is unable to cough productively; also permits the use of positive pressure for ventilation, and prevents aspiration of secretions in the unconscious or paralyzed patient

(Kaplan Resp Set 7/30)

The nurse monitors a patient receiving oxygen per face mask. The nurse is MOST concerned if which is observed?

a) there is condensation in the tubing of the humidifier container
b) the pulse oximetry reading is 92%
c) the patient has a nonproductive cough
d) the skin under the elastic band is reddened

(Kaplan Resp Set 8/30)
c) nonproductive cough is an early symptom of oxygen toxicity; other early symptoms include nasal congestion, sore throat, substernal discomfort or pain, GI upset, dyspnea; later symptoms include decreased vital capacity, increased dyspnea, crackles, hypoxemia; atelectasis or structural damage to the lungs, along with pulmonary edema and hemorrhage and stiffness of lung tissue can occur; this syndrome is known as Adult Respiratory Distress Syndrome (ARDS); treatment of the toxic effects is very difficult, and prevention is a priority

(Kaplan Resp Set 8/30)

The nurse identifies which is the characteristic sound of breathing in a patient experiencing an acute asthma attack?

a) murmuring, with “lubb”/”dub” sounds
b) high-pitched musical-like squeaky sounds
c) high-pitched harsh, loud, blowing sounds
d) low-pitched rubbing or grating sounds

(Kaplan Resp Set 9/30)
b) describes wheezes, heard primarily during expiration but may also be heard on inspiration; caused by air passing through narrowed airways’ auscultated over small airways; heard in cases of acute asthma or chronic emphysema

(Kaplan Resp Set 9/30)

The nurse identifies which group of equipment is essential to have at the bedside of a patient with a closed-chest chest tube drainage system in place?

a) tape measure, portable scale, Sengstaken-Blakemore tube
b) penlight, reflex hammer, safety pin
c) sterile connector, sterile petrolatum gauze pad, padded clamp
d) nasogastric tube, blood glucose monitor, sputum jar

(Kaplan Resp Set 10/30)
c) all are related to management of chest tubes, particularly emergencies; sterile connector is used to reestablish drainage system if tubing disconnects from the drainage equipment; gauze pad is used if chest tube dislodges from body of patient, forming a seal so atmospheric air cannot get into the negative pressure thoracic cavity; padded clamp is used, briefly and with extreme caution, to assess for possible air leaks and also prior to removing chest tube

(Kaplan Resp Set 10/30)

The nurse cares for a patient with a new tracheostomy immediately postop. It is MOST important for the nurse to take which action?

a) place the patient supine until vital signs are stable
b) ask the patient which position makes the patient most comfortable
c) place the patient with head elevated and neck hyperextended
d) elevate the patient’s head and turn the head to one side until consciousness returns

(Kaplan Resp Set 11/30)
d) semi-Fowler’s position facilitates respiration, promotes drainage, prevents edema, and prevents strain on the suture line

(Kaplan Resp Set 11/30)

The nurse identifies which patient is MOST at risk for developing pneumonia?

a) a patient with a Foley catheter
b) a patient with a nasogastric (NG) tube
c) a patient diagnosed with psoriasis
d) a patient diagnosed with Paget’s disease

(Kaplan Resp Set 12/30)
b) nasogastric tube is inserted through the nose and ends in the stomach; used for enteral nutrition to deliver liquid nourishment when GI tract cannot be used; if it is not in proper position before infusion of food, aspiration into the lungs can result, with subsequent chocking and inflammatory process of aspiration pneumonia; tube placement must be verified with aspiration of gastric contents and checking the pH (pH of 0-4 indicates gastric placement, pH of approximately 6 or more indicates placement in lungs); X-ray may also be used to verify placement; in addition, if NG tube becomes obstructed and patient vomits, gastric acid and stomach contents can enter the lungs

(Kaplan Resp Set 12/30)

A client chokes on food and becomes cyanotic. Which is the best action for the nurse to take?

a) the nurse stands behind the client, and with the palm of the hand delivers one quick blow to the middle of the back
b) the nurse stands behind the client, wraps arms around the client’s waist, and with a fist makes a quick upward thrust into the abdomen
c) the nurse stands in front of the client, puts the palm of the hand between the navel and rib cage, and presses firmly upward several times
d) the nurse lays the client on the floor and prepares to initiate cardiopulmonary resuscitation

(Kaplan Resp Set 13/30)
b) if the person is choking the abdominal-thrust maneuver should be performed; by making quick upward thrusts, the pressure is increased in the thoracic cavity, and the air that is normally trapped in the lungs acts as an upward force to push the obstruction out of the airway

(Kaplan Resp Set 13/30)

The nurse on the neurologic unit knows that which is the primary reason for having a patient diagnosed with a cardiovascular accident (CVA) position the head flexed slightly forward when sitting upright to eat?

a) to increase the ease of swallowing
b) to decrease the musculature effort of maintaining the head erect
c) to decrease anxiety from seeing feeding utensils coming directly at them
d) to prevent aspiration

(Kaplan Resp Set 14/30)
d) when the head is flexed slightly forward when the patient is seated erect it closes the epiglottis, thus preventing aspiration; the epiglottis is a cartilaginous structure hanging over the larynx like a lid; when it closes, food or secretions cannot enter the larynx of the trachea; the trachea extends from the larynx to the mainstem bronchi; this flexed positioning is also used for any patient during nasogastric (NG) tube insertion to ensure the tube goes into the stomach and not the lungs

(Kaplan Resp Set 14/30)

Albbuterol (Proventil) and beclomethasone (Vanceril) by metered dose inhaler (MDI) are ordered for a patient recently diagnosed with asthma. The patient asks the nurse, “Why do I have to be concerned about which medication I take first and waiting in between medications?” Which is the BEST response by the nurse?

a) “that is how your physician wrote the order.”
b) “you do not have to be concerned. you can take them in whatever way works best for you as long as you take them both.”
c) “that is the standard way these medications are administered.”
d) “the proventil will open up the airway so the vanceril can be better absorbed. you want to allow the proventil to have its full effect.”

(Kaplan Resp Set 15/30)
d) the albuterol (Proventil) is a bronchodilator; it will open the airway so the beclomethasone (Vanceril), which is a steroid, will be absorbed; the 5 minute wait allows for this airway opening to occur; the steroid functions to directly affect smooth muscle relaxation to enhance the effect of some bronchodilators and also to inhibit inflammation that could result in bronchoconstriction

(Kaplan Resp Set 15/30)

A patient is diagnosed with a tension pneumothorax resulting from the chest hitting the steering wheel in an automobile accident. The emergency department nurse knows that highest priority is given to which?

a) oxygenation
b) chest tube insertion
c) arterial blood gas (ABG) determination
d) attaching a cardiac monitor

(Kaplan Resp Set 16/30)
b) tension pneumothorax is an extremely serious emergency, even more than an open pneumothorax; motor vehicle accidents and blunt chest trauma are two potential causes; tension pneumothorax results from air moving into the pleural space and not being able to move back out; pressure builds up in the chest and if it is untreated, the heart, trachea, esophagus, and great vessels are shifted toward the unaffected side due to the lung on the affected side collapsing; further compromise of respiratory and circulatory function ensues; immediate intervention is to insert chest tubes with suction drainage in order to convert the tension pneumothorax into an open pneumothorax; thoracentesis to remove air may be used if chest tube insertion is delated

(Kaplan Resp Set 16/30)

The nurse instructs a group of high school students how to perform the abdominal-thrust maneuver. The nurse determines that teaching is successful if a student makes which comment?

a) “the abdominal-thrust maneuver dislodges food or other foreign bodies from the airway.”
b) “the abdominal-thrust maneuver involves hitting the person on the back several times.”
c) “the abdominal-thrust maneuver should not be done if the person is pregnant.”
d) “the abdominal-thrust maneuver should only be done by a well-trained health care professional.”

(Kaplan Resp Set 17/30)
a) hands crossed at neck is universal sign of chocking; abdominal-thrust maneuver is used to dislodge food or other foreign bodies in the airway

(Kaplan Resp Set 17/30)

The outer cannula of a patient’s tracheostomy tube is accidentally expelled 36 hours after surgery. Which action should the nurse take FIRST?

a) contact the physician immediately
b) cut the tracheostomy neck ties
c) insert the emergency outer tube that is taped to the head of the bed
d) ventilate the chest using a manual resuscitation bag

(Kaplan Resp Set 18/30)
d) nurse should use a manual resuscitation bag to ventilate the patient while another staff member contacts the resuscitation team; if nurse tries to insert a tube in a new (under 72 hours) tracheostomy, may cause tissue damage because the tract is not matured

(Kaplan Resp Set 18/30)

The patient diagnosed with cholecystitis is blind. In preparation for surgery, the nurse teaches the patient diaphragmatic breathing. Which is the MOST effective teaching method for the nurse to use?

a) the nurse demonstrates diaphragmatic breathing and then asks the patient do a return demonstration
b) the nurse discusses the rationale behind postoperative abdominal breathing, outlines the steps, and answers questions
c) the nurse asks the patient to put both hands on the abdomen and breathe in and out while keeping the chest still
d) the nurse asks the patient to tighten and release muscles, progressing from the toes to the head

(Kaplan Resp Set 19/30)
c) diaphragmatic or abdominal breathing requires the chest to remain still while the abdominal muscles do the work of breathing; a book on the abdomen with the hands of the patient resting on top of it, or just the hands themselves, provides some resistance and also something a patient can see (or in the case of this patient who is blind-sense or feel) that indicates they are breathing deeply and correctly enough as the abdomen rises and falls

(Kaplan Resp Set 19/30)

Which sign or symptom, if observed by the nurse, is MOST important to determine if a patient is hypoxic?

a) cool, bluish skin
b) abnormal blood gases
c) elevated temperature
d) increased sputum production

(Kaplan Resp Set 20/30)
b) blood gases measure tissue oxygenation, carbon dioxide removal, and acid-base balance; if patient has inadequate exchange of oxygen and carbon dioxide, respiratory acidosis occurs

(Kaplan Resp Set 20/30)

An adult is in a motorcycle accident and sustains three fractured ribs and a pneumothorax. A chest tube is inserted. The nurse should take which of the following actions?

a) monitor the fluctuation in the tube
b) pin the tubes to the sheets
c) clamp the tubes when transferring the patient to bed
d) empty the bottles every eight hours

(Kaplan Resp Set 21/30)
a) a closed drainage that enables air and blood to drain from the pleural space; cessation of fluctuation may indicate blockage of the tube, or that the lung has re-expanded; fluctuation in the tube should be monitored

(Kaplan Resp Set 21/30)

The nurse performs discharge teaching for a patient diagnosed with chronic obstructive pulmonary disease (COPD). The client asks if the oxygen concentration can be increased during periods of shortness of breath. On what is the nurse’s response based?

a) high-low oxygen interferes with breathing
b) low-flow oxygen will not improve breathing
c) high-flow oxygen will stimulate breathing
d) low-flow oxygen is more comfortable

(Kaplan Resp Set 22/30)
a) patients with COPD are stimulated to breathe not by increasing levels of carbon dioxide, but by a decreased level of oxygen in the blood; if high-flow oxygen is provided to these patients, it eliminates their drive to breathe

(Kaplan Resp Set 22/30)

The nurse prepares a patient for a thoracentesis. The nurse should position the patient in which position?

a) Semi-Fowler’s
b) upright
c) on the affected side
d) prone

(Kaplan Resp Set 23/30)
b) a thoracentesis is the aspiration of pleural fluid or air from the pleural space; sitting upright on the edge of the bed allows for the best lung expansion, and allows for good access to the area which will be used for the procedure

(Kaplan Resp Set 23/30)

The nurse performs teaching for a patient diagnosed with tuberculosis. The nurse explains that tuberculosis is caused by which?

a) a virus
b) poor sanitation
c) poor nutrition
d) a bacterium

(Kaplan Resp Set 24/30)
d) caused by the bacterium Mycobacterium tuberculosis, transmitted via the aerosol route (coughing, laughing, sneezing, or singing);

(Kaplan Resp Set 24/30)

The home care nurse visits a client diagnosed with chronic bronchitis. The nurse notes the client is weak and congested. It is MOST important for the nurse to make which assessment?

a) “Cough as much as you can. The secretions have to come out.”
b) “If you hold a pillow against your abdomen, the coughing would be easier.”
c) “Take 3 or 4 deep breaths, and as you exhale the last breath, cough 3 times.”
d) “It does not matter when you cough. Just do it>”

(Kaplan Resp Set 25/30)
c) the client should sit with feet on the floor, lean slightly forward, and take several slow deep breaths through the nose; exhalations should be slow through pursed lips; during exhalation of the last breath the client should cough several times; mucus is moved up the respiratory tree more effectively with several consecutive coughs than with a single one

(Kaplan Resp Set 25/30)

The nurse understands the primary mechanism of action of synchronized intermittent mandatory ventilation (SIMV) for a patient requiring respiratory support is which?

a) the delivery of breaths is synchronized with the R wave of the patient
b) a set tidal volume is delivered at a set rate regardless of the breathing efforts of the patient
c) positive pressure is intermittently exerted at the end of ventilator breaths
d) ventilator breaths are correlated with patient breathing and patient can breathe naturally in between

(Kaplan Resp Set 26/30)
d) describes synchronized intermittent mandatory ventilation (SIMV); preset tidal volume and rate are established; delivery to patient is synchronized with patient inspiration; patient can breathe spontaneously at own tidal volume and rate in between ventilator breaths, using an oxygen reservoir attached to the machine; SIMV is used both as a primary ventilation mode for a wide variety of clinical conditions, as well as as a weaning modality

(Kaplan Resp Set 26/30)

The client arrives in the emergency room with an acute asthma attack. Epinephrine is given subcutaneously. Which observation by the nurse BEST indicates the treatment is effective?

a) an increase in the client’s alertness
b) an increase in the client’s pulse rate
c) a decrease in the client’s blood pressure and pulse
d) a decrease in the client’s inspiratory difficulty

(Kaplan Resp Set 27/30)
d) asthma is a chronic inflammatory disease of the airways that causes reversible airflow obstruction, airway inflammation, and airway hyper-responsiveness; symptoms include cough, chest tightness, wheezing, and dyspnea; is reversible; decreased inspiratory difficulty indicates effective treatment; epinephrine is a bronchodilator, which relaxes the smooth muscles and decreases difficulty in inspiration

(Kaplan Resp Set 27/30)

The nurse assesses a patient receiving isoniazid (INH). It is MOST important for the nurse to observe for which?

a) hepatitis
b) glomerulonephritis
c) photosensitivity
d) deafness

(Kaplan Resp Set 28/30)
a) hepatitis is a side effect of INH; teach signs of hepatitis and check liver function tests; instruct patient to avoid alcohol; other side effects include peripheral neuritis, rash, and fever

(Kaplan Resp Set 28/30)

The nurse instructs a patient about how to use an incentive spirometer. The nurse determines that teaching is effective if the patient makes which statement?

a) “I should take a deep breath and blow into the mouthpiece.”
b) “I’m glad that I only have to do it twice a day.”
c) “I should ask for pain medication prior to using the spirometer.”
d) “I should take lie down to use the incentive spirometer.”

(Kaplan Resp Set 29/30)
c) the incentive spirometer is used after thoracic and abdominal surgery to prevent atelectasis, to encourage deep inspirations; nursing responsibilities include assessing the patient’s level of pain and administering the pain medication as ordered

(Kaplan Resp Set 29/30)

The nurse cares for a patient receiving aminophylline. The nurse identifies which is a common side effect of aminophylline?

a) increased respiratory rate
b) increased pulse rate
c) decreased respiratory rate
d) decreased pulse rate

(Kaplan Resp Set 30/30)
b) aminyphylline is a therapeutic bronchodilator and a pharmacologic xanthine known to cause tachycardia, nervousness, restlessness, and nausea; must be used cautiously in patients with cardiac impairment

(Kaplan Resp Set 30/30)