NCLEX Practice Exam for Respiratory System 1

EXPLANATION

✔Correct answer:

Pneumonia. Pneumonia is the most common complication of influenza, particularly in elderly patients. Influenza can weaken the immune system and the respiratory tract's defenses, making it easier for bacteria to infect the lungs and cause pneumonia. Viral pneumonia can also develop directly from the influenza virus. Given the increased vulnerability of elderly patients, close monitoring for signs and symptoms of pneumonia, such as increased cough, sputum production, fever, dyspnea, and chest pain, is essential.

Influenza primarily affects the respiratory system, causing inflammation and weakening of the epithelial lining of the respiratory tract. This creates an environment conducive to secondary bacterial infections, commonly leading to pneumonia. In some cases, the influenza virus itself can cause a severe viral pneumonia.

Think of the respiratory tract like a fortress. Influenza is like a storm that damages the fortress walls (respiratory epithelium), making it easier for invaders (bacteria) to breach the defenses and cause further damage (pneumonia).

Nurse Lee should vigilantly monitor Mr. Johnson for signs of pneumonia, including:

• Assessing lung sounds for crackles or decreased breath sounds.
• Monitoring oxygen saturation and respiratory rate.
• Observing for increased sputum production and changes in its color or consistency.
• Checking for signs of systemic infection such as fever and increased white blood cell count.
• Ensuring the patient adheres to prescribed treatments, such as antiviral medications and supportive care, to minimize the risk of complications.

✘Incorrect answer options:

Septicemia While septicemia (bloodstream infection) can occur as a severe complication of influenza, it is not as common as pneumonia. Septicemia generally results from severe secondary bacterial infections, including pneumonia, but pneumonia remains the more frequent initial complication.

Meningitis Meningitis, an inflammation of the protective membranes covering the brain and spinal cord, is not a common complication of influenza. While viral infections can sometimes lead to viral meningitis, it is much less common than respiratory complications like pneumonia.

Pulmonary edema Pulmonary edema, the accumulation of fluid in the lungs, is not typically associated with influenza. It is more commonly related to cardiac issues or other underlying conditions such as heart failure. Influenza primarily affects the respiratory system and leads to complications like pneumonia rather than fluid accumulation.

EXPLANATION

✔Correct answer:

Albuterol (Proventil). Albuterol is a beta-2 agonist that works as a bronchodilator. It is commonly used in the treatment of acute asthma exacerbations to relieve bronchospasm and improve airflow. Mr. Johnson's symptoms, including a high respiratory rate, wheezing, and low arterial blood oxygen saturation, indicate that he is experiencing significant bronchospasm. Administering albuterol can help relax the bronchial smooth muscles, leading to bronchodilation and improved oxygenation.

During an asthma attack, inflammation and bronchospasm lead to narrowing of the airways, making it difficult to breathe. Albuterol binds to beta-2 adrenergic receptors in the smooth muscle of the airways, causing relaxation and widening of the airways (bronchodilation). This helps to alleviate wheezing, reduce respiratory distress, and improve oxygen saturation.

Think of albuterol like an emergency roadside service that clears a traffic jam (bronchospasm) on a busy highway (airway), allowing cars (air) to flow freely again.

Nurse Jackson should administer albuterol via a nebulizer or metered-dose inhaler with a spacer to ensure the medication is delivered effectively to the lower airways. The nurse should monitor Mr. Johnson's respiratory status, including respiratory rate, lung sounds, and oxygen saturation, to assess the effectiveness of the treatment and to detect any adverse effects.

• Administer albuterol as prescribed, typically via nebulizer or metered-dose inhaler.
• Monitor the patient’s respiratory status, including respiratory rate, lung sounds, and oxygen saturation, after administration.
• Assess for side effects of albuterol, such as tachycardia, tremors, or nervousness.
• Continue to provide supplemental oxygen as needed to maintain adequate oxygen saturation.
• Educate the patient on the use of albuterol and the importance of seeking immediate medical help for severe asthma exacerbations.

✘Incorrect answer options:

Alprazolam (Xanax). While alprazolam is an anxiolytic that can help reduce anxiety, it does not address the underlying bronchospasm and airway obstruction causing Mr. Johnson’s respiratory distress. Administering albuterol, which directly treats bronchospasm, is a priority.

Propranolol (Inderal). Propranolol is a non-selective beta-blocker that can actually worsen bronchospasm by blocking beta-2 receptors in the bronchial smooth muscle, making it contraindicated in patients with asthma.

Morphine. Morphine is an opioid analgesic that can depress respiration and is not indicated in the treatment of bronchospasm. It could potentially worsen respiratory status in a patient experiencing acute respiratory distress.

EXPLANATION

✔Correct answer:

It helps prevent early airway collapse. Pursed-lip breathing is a technique used by patients with emphysema to improve their breathing efficiency. This method helps to maintain positive airway pressure during exhalation, which helps to keep the airways open for a longer duration and prevents early airway collapse. By doing so, it facilitates better gas exchange and reduces the work of breathing.

Emphysema is characterized by the destruction of the alveolar walls and loss of lung elasticity, leading to collapsed airways, particularly during exhalation. Pursed-lip breathing creates back pressure in the airways, which helps to keep them open longer, allowing more complete exhalation of air and reducing the amount of trapped air in the lungs. This technique helps to reduce the feeling of shortness of breath and improve overall respiratory function.

Imagine trying to slowly deflate a party balloon by pinching its opening slightly. By controlling the rate at which the air escapes, you prevent the balloon from collapsing too quickly, allowing a more gradual and controlled deflation. Similarly, pursed-lip breathing helps to keep the airways open longer during exhalation, preventing them from collapsing prematurely and ensuring more efficient airflow out of the lungs.

Nurse Patel should educate Mrs. Wilson on the correct technique for pursed-lip breathing and its benefits. This includes demonstrating the method, ensuring proper practice, and encouraging regular use, especially during episodes of shortness of breath or physical activity.

• Instruct Mrs. Wilson to inhale slowly through her nose for about two counts.
• Then, have her purse her lips as if she is about to whistle and exhale slowly and gently through her lips for about four counts.
• Encourage her to practice this technique regularly, particularly during activities that cause shortness of breath.
• Explain that this method can help her feel more in control of her breathing and reduce anxiety associated with breathlessness.

✘Incorrect answer options:

It increases the strength of inspiratory muscles. Pursed-lip breathing primarily focuses on exhalation rather than strengthening inspiratory muscles. Its main goal is to improve exhalation and prevent airway collapse.

It reduces the use of accessory breathing muscles. While pursed-lip breathing can help make breathing more efficient and less laborious, its primary benefit is preventing airway collapse rather than directly reducing the use of accessory muscles. The use of accessory muscles may still be necessary in patients with severe emphysema.

It prolongs the inspiratory phase of breathing. Pursed-lip breathing does not primarily aim to prolong the inspiratory phase. Instead, it focuses on prolonging the exhalation phase to prevent airway collapse and improve ventilation.

EXPLANATION

✔Correct answer:

Extreme anxiety. Respiratory alkalosis occurs when there is a decrease in carbon dioxide (CO₂) levels in the blood due to hyperventilation. Extreme anxiety can lead to hyperventilation, which causes excessive expulsion of CO₂, resulting in an increase in blood pH (alkalosis).

When a person is extremely anxious, they may begin to breathe more rapidly and deeply (hyperventilate). This rapid breathing expels more CO₂ than the body is producing, leading to a decrease in CO₂ levels (hypocapnia). CO₂ is acidic in solution, so its loss results in a relative increase in blood alkalinity (pH), causing respiratory alkalosis.

Think of CO₂ as a weight that balances a seesaw. Hyperventilation removes too much of this weight (CO₂), causing the seesaw to tip too far towards alkalinity (high pH).

Nurse Kelly should assess Ms. Roberts for signs of hyperventilation and anxiety. Interventions may include providing a calm environment, encouraging slow and controlled breathing techniques, and addressing the underlying cause of anxiety. Monitoring the patient's arterial blood gases (ABGs) can help track the severity of respiratory alkalosis and guide treatment.

• Encourage slow, deep breaths or the use of a paper bag to rebreathe CO₂ if appropriate.
• Provide emotional support and relaxation techniques to reduce anxiety.
• Monitor arterial blood gases (ABGs) to assess the extent of alkalosis and response to interventions.
• Educate the patient on recognizing and managing hyperventilation episodes.

✘Incorrect answer options:

Myasthenia gravis. This condition is associated with respiratory acidosis rather than alkalosis. Myasthenia gravis can cause respiratory muscle weakness, leading to hypoventilation and CO₂ retention, which results in respiratory acidosis.

Type 1 diabetes mellitus. This condition is more commonly associated with metabolic acidosis (such as diabetic ketoacidosis) rather than respiratory alkalosis. In diabetic ketoacidosis, the body produces excessive ketones, leading to a decrease in blood pH.

Narcotic overdose. Narcotic overdose typically leads to respiratory depression, resulting in hypoventilation and CO₂ retention. This causes respiratory acidosis, not alkalosis.

EXPLANATION

✔Correct answer:

5 to 20 minutes. When weaning a patient off a tracheostomy, the initial plugging of the tracheostomy tube opening is typically done for a short period to assess the patient's ability to tolerate breathing without assistance. Starting with 5 to 20 minutes allows the healthcare team to monitor the patient's respiratory status, oxygenation, and comfort level. This duration is generally considered safe and sufficient to evaluate the patient’s ability to handle the change while avoiding overwhelming the respiratory system.

The tracheostomy tube bypasses the upper respiratory tract, providing a direct airway. When transitioning away from the tracheostomy, the goal is to allow the patient to gradually adapt to breathing normally through the upper airway again. Beginning with shorter intervals and gradually increasing the duration helps ensure the patient can manage the transition safely.

Imagine you're training a plant to survive outside after being kept indoors. You wouldn't place it in direct sunlight for a full day initially; instead, you'd expose it to sunlight for a short period and gradually increase the exposure. Similarly, the weaning process starts with short intervals and gradually increases as the patient adapts.

Nurse Ramirez should follow these steps during the initial tracheostomy tube plugging:

• Explain the procedure to Ms. Lopez to reduce anxiety and ensure cooperation.
• Monitor Ms. Lopez's respiratory rate, oxygen saturation, and overall comfort closely during the 5 to 20-minute plugging period.
• Observe for any signs of respiratory distress, such as increased work of breathing, use of accessory muscles, or changes in mental status.
• If Ms. Lopez tolerates the initial period well, the plugging duration can be gradually increased in subsequent sessions based on her tolerance and clinical condition.
• Ensure emergency equipment is readily available in case immediate intervention is needed.

✘Incorrect answer options:

15 to 60 seconds This duration is too short to effectively assess the patient’s ability to tolerate breathing through the upper airway. Such a brief period is insufficient for a meaningful evaluation.

30 to 40 minutes Starting with 30 to 40 minutes can be overwhelming for a patient who is not yet accustomed to breathing through the upper airway. This duration is typically used later in the weaning process after shorter intervals have been successfully tolerated.

45 to 60 minutes A 45 to 60-minute initial trial is too long and can lead to significant respiratory distress if the patient is not prepared. Such an extended duration should only be attempted after the patient has successfully tolerated shorter periods without issues.

EXPLANATION

✔Correct answer:

Vancomycin should be infused over 60 to 90 minutes in a substantial volume of fluid. Vancomycin is an antibiotic used to treat serious bacterial infections, particularly those caused by Gram-positive organisms. It is essential to infuse vancomycin over 60 to 90 minutes to reduce the risk of infusion-related reactions, including "red man syndrome," which is characterized by flushing, rash, and hypotension due to histamine release. Infusing the medication slowly in a substantial volume of fluid helps ensure it is well-tolerated and minimizes the risk of adverse effects.

Rapid administration of vancomycin can lead to high peak serum concentrations, which can cause adverse reactions such as ototoxicity, nephrotoxicity, and infusion-related reactions. By infusing vancomycin over 60 to 90 minutes, the drug's serum levels increase more gradually, reducing the risk of these complications.

Administering vancomycin slowly is like watering a plant gradually to ensure the water is absorbed properly without overwhelming the soil, compared to dumping a large amount of water all at once, which could flood and damage the plant.

Nurse Jackson should ensure that vancomycin is administered over the appropriate time frame and monitor Mr. Daniels for any signs of adverse reactions during the infusion. Additionally, it is important to regularly check renal function and hearing, as vancomycin can be nephrotoxic and ototoxic.

• Infuse vancomycin over 60 to 90 minutes in a substantial volume of fluid, typically 250-500 ml.
• Monitor the patient for signs of "red man syndrome" or other infusion-related reactions.
• Assess renal function by monitoring serum creatinine and urine output before and during therapy.
• Observe for signs of ototoxicity, such as tinnitus or hearing loss, especially in patients receiving higher doses or prolonged therapy.
• Educate the patient about the importance of reporting any unusual symptoms, such as rash, itching, or changes in hearing.

✘Incorrect answer options:

Vancomycin may potentially cause irreversible neutropenia. While vancomycin can cause neutropenia, it is generally reversible upon discontinuation of the drug. This side effect is relatively rare compared to the more common risks of nephrotoxicity and infusion-related reactions.

Vancomycin should be administered quickly in a large volume of fluid. Administering vancomycin quickly can increase the risk of infusion-related reactions and adverse effects, such as "red man syndrome." The medication should be infused slowly to ensure safe administration.

Vancomycin should be given over 1 to 2 minutes as an I.V. bolus. Administering vancomycin as a rapid I.V. bolus is contraindicated due to the high risk of severe adverse reactions, including hypotension and "red man syndrome." The medication must be infused slowly to prevent these complications.

EXPLANATION

✔Correct answer:

The partial pressure of arterial oxygen (PaO2). To assess the effectiveness of supplemental oxygen therapy, the most critical arterial blood gas (ABG) value to evaluate is the partial pressure of arterial oxygen (PaO2). PaO2 indicates the amount of oxygen dissolved in the blood and is a direct measure of the oxygenation status of the patient. By monitoring PaO2, Nurse Olivia can determine if the supplemental oxygen therapy is effectively increasing the oxygen levels in Ms. Roberts's blood.

PaO2 reflects the ability of the lungs to transfer oxygen from the air into the blood. In conditions like hypoxemia, PaO2 is reduced, and supplemental oxygen therapy is used to increase PaO2 to ensure adequate tissue oxygenation. A normal PaO2 value typically ranges from 75 to 100 mm Hg. An improvement in PaO2 after administering supplemental oxygen indicates that the therapy is effective.

Think of PaO2 like the fuel gauge in a car. Just as you check the fuel gauge to see if the car has enough gas to run efficiently, checking PaO2 helps determine if the blood has enough oxygen to meet the body's needs.

Nurse Olivia should regularly monitor Ms. Roberts's PaO2 levels through ABG analysis to evaluate the effectiveness of the oxygen therapy. She should also observe for clinical signs of improved oxygenation, such as increased oxygen saturation (SpO2), improved skin color, and reduced symptoms of hypoxia.

✘Incorrect answer options:

The pH level. While important for assessing overall acid-base balance, the pH level does not directly measure the effectiveness of oxygen therapy.

The bicarbonate (HCO3–) concentration. Bicarbonate levels are important for evaluating metabolic components of acid-base balance but do not directly reflect the effectiveness of oxygen therapy.

The partial pressure of arterial carbon dioxide (PaCO2). PaCO2 measures the amount of carbon dioxide in the blood and is important for assessing ventilation status, but it does not directly measure oxygenation status. It is more relevant to evaluating respiratory function and conditions like hypercapnia or hypocapnia.

EXPLANATION

✔Correct answer:

Applying a high-flow Venturi mask to deliver prescribed oxygen. For a patient with COPD, maintaining adequate gas exchange is crucial, and precise oxygen delivery is essential. The high-flow Venturi mask is the most effective nursing action because it delivers a controlled and consistent concentration of oxygen, which helps in maintaining adequate oxygen levels without risking hypercapnia. Patients with COPD often have a diminished sensitivity to carbon dioxide, and uncontrolled oxygen delivery can lead to a dangerous buildup of CO₂ (hypercapnia).

COPD, which includes chronic bronchitis and emphysema, results in chronic airflow limitation and impaired gas exchange. These patients often have a reliance on hypoxic drive to breathe, and administering oxygen at carefully controlled levels prevents the risk of reducing their respiratory drive. The Venturi mask allows for precise regulation of oxygen concentrations, which is crucial for avoiding the potential adverse effects of high oxygen levels in COPD patients.

Using a Venturi mask is like using a finely tuned faucet to deliver the exact amount of water needed. It ensures the patient gets just the right amount of oxygen, not too much and not too little.

Nurse Andrews should apply the high-flow Venturi mask as prescribed and monitor Mr. Thompson's oxygen saturation levels regularly. This ensures that the patient is receiving the appropriate oxygen concentration and helps detect any signs of respiratory distress or changes in blood gas levels.

• Apply the high-flow Venturi mask according to the prescribed oxygen concentration.
• Regularly monitor the patient's oxygen saturation and respiratory rate.
• Assess for signs of hypercapnia, such as confusion, headache, or increased drowsiness.
• Educate the patient on the importance of using the oxygen delivery device as prescribed.

✘Incorrect answer options:

Encouraging the patient to consume three glasses of fluid daily. Adequate hydration is important for COPD patients to help thin mucus secretions, but three glasses of fluid daily may be insufficient. Additionally, this action does not directly address gas exchange.

Positioning the patient in a semi-Fowler's position. While the semi-Fowler's position can aid in breathing by reducing pressure on the diaphragm and improving lung expansion, it is not as directly effective as controlled oxygen delivery in ensuring adequate gas exchange.

Administering a prescribed sedative. Sedatives can depress the respiratory system and potentially worsen gas exchange in COPD patients. This option could be harmful, as it may lead to hypoventilation and decreased oxygenation.

EXPLANATION

✔Correct answer:

Being overweight. For a patient with chronic bronchitis, being overweight can significantly elevate oxygen demands. Excess body weight increases the work of breathing and places additional strain on the cardiovascular and respiratory systems. This can exacerbate symptoms of dyspnea (difficulty breathing) and further compromise oxygenation. By avoiding being overweight, the patient can help reduce the stress on their respiratory system, thus improving their ability to tolerate activity.

Chronic bronchitis is a form of chronic obstructive pulmonary disease (COPD) characterized by inflammation of the bronchi, increased mucus production, and persistent cough. Excess weight can compress the diaphragm and reduce lung expansion, leading to decreased ventilation and gas exchange. Additionally, adipose tissue is metabolically active and increases the body's oxygen demand, exacerbating the patient's dyspnea and activity intolerance.

Think of the respiratory system like a balloon that needs to inflate and deflate easily. Being overweight is like adding extra weights on top of the balloon, making it harder to expand and contract effectively.

Nurses should provide education and support for weight management, including dietary counseling and encouragement of safe physical activities to help maintain a healthy weight. This can improve overall respiratory function and activity tolerance.

• Encourage a balanced diet that supports weight management.
• Promote regular, moderate exercise as tolerated and as prescribed by the healthcare provider.
• Monitor the patient's weight regularly and provide resources for weight loss programs if needed.
• Educate the patient on the benefits of maintaining a healthy weight for respiratory function.

✘Incorrect answer options:

Consuming more than 1,500 ml of fluids daily. Maintaining adequate hydration is important for patients with chronic bronchitis to help thin mucus secretions and facilitate their clearance from the airways. Restricting fluid intake could lead to thicker secretions and more difficulty in breathing.

Having a high-protein snack before bed. Protein intake is important for maintaining muscle mass and overall health, and having a high-protein snack before bed can help stabilize blood sugar levels overnight. This choice does not significantly impact oxygen demands.

Eating more than three large meals in a day. Eating multiple smaller meals throughout the day can actually be beneficial for patients with respiratory conditions, as large meals can increase the work of breathing by causing abdominal distention and pressure on the diaphragm. Small, frequent meals can help maintain energy levels without overburdening the respiratory system.

EXPLANATION

✔Correct answer:

Between 7.35 and 7.45. The normal pH range for arterial blood is between 7.35 and 7.45. This range is crucial for maintaining the body's acid-base balance and proper physiological function. A pH below 7.35 indicates acidosis, while a pH above 7.45 indicates alkalosis.

The body tightly regulates arterial pH through buffer systems, respiratory control, and renal regulation to ensure that the pH remains within this narrow range. Deviations from this range can disrupt cellular functions and enzyme activities, leading to significant clinical complications.

Think of the pH range like the temperature range for storing food in a refrigerator. Just as food needs to be kept within a certain temperature range to stay fresh and safe to eat, the body's pH needs to stay within a specific range to function properly.

Nurse Ava should continue to monitor Mr. Clark’s ABG values, ensuring that his pH remains within the normal range. If the pH is outside this range, further assessment and intervention are needed to address underlying conditions causing the imbalance.

✘Incorrect answer options:

From 7 to 7.49 This range is too broad and includes values that are too low (indicative of severe acidosis) and too high (indicative of alkalosis).

Ranging from 7.50 to 7.60 This range is too high, indicating alkalosis. The normal physiological pH does not extend to 7.50 or higher.

From 7.55 to 7.65 This range is significantly higher than normal and would indicate severe alkalosis. Such a pH range is not compatible with normal physiological function.

EXPLANATION

✔Correct answer:

Hypoxia. The symptoms observed in Mrs. Clarke—wheezing, bradycardia (slow heart rate), and a respiratory rate of 10 breaths per minute—are indicative of hypoxia. Hypoxia refers to a deficiency in the amount of oxygen reaching the tissues. In patients with advanced lung cancer, hypoxia can occur due to several reasons, such as obstructed airways, impaired gas exchange, or reduced lung capacity.

Hypoxia occurs when there is insufficient oxygen in the blood to meet the metabolic demands of the body's tissues. In patients with lung cancer, tumors can obstruct airways or cause pleural effusion, leading to decreased oxygenation. The body responds to hypoxia by initially increasing the respiratory rate; however, as the condition progresses and the respiratory muscles fatigue, the rate may decrease, leading to bradycardia and other signs of severe oxygen deprivation.

Think of hypoxia like a car running out of fuel. Initially, the car may sputter and slow down, and if not refueled, it will eventually stop. Similarly, the body initially tries to compensate for low oxygen by increasing breathing efforts, but if the oxygen levels continue to drop, the body's vital functions, like heart rate and respiratory rate, will slow down.

Nurse Stevens should take immediate action to address the hypoxia:

• Administer supplemental oxygen as prescribed to improve oxygen saturation levels.
• Position Mrs. Clarke in a semi-Fowler’s position to facilitate easier breathing.
• Monitor vital signs closely, including respiratory rate, heart rate, and oxygen saturation.
• Assess for any signs of airway obstruction and manage according to protocol (e.g., suctioning if necessary).
• Notify the healthcare provider of the patient's condition to consider further interventions, such as medication adjustments or additional diagnostic tests.

✘Incorrect answer options:

Delirium Delirium is characterized by acute confusion, disorientation, and fluctuations in consciousness. While it can occur in patients with advanced illness, it is not directly indicated by the respiratory and cardiovascular symptoms described (wheezing, bradycardia, and a low respiratory rate).

Hyperventilation Hyperventilation involves rapid or deep breathing that leads to decreased levels of carbon dioxide in the blood. Symptoms typically include a high respiratory rate, tingling in the extremities, and dizziness, which are not consistent with Mrs. Clarke's presentation.

Semiconsciousness Semiconsciousness refers to a state where a patient is partially but not fully aware of their surroundings. While hypoxia can lead to altered levels of consciousness, the specific symptoms of wheezing, bradycardia, and low respiratory rate more directly point to hypoxia as the underlying cause rather than semiconsciousness as a primary condition.

EXPLANATION

✔Correct answer:

10 to 20 mcg/ml. Theophylline is a bronchodilator used to treat symptoms of asthma and other respiratory conditions. It works by relaxing the smooth muscles in the airways, thereby improving airflow. The therapeutic concentration range for theophylline is 10 to 20 mcg/ml. Monitoring serum theophylline levels is crucial because the drug has a narrow therapeutic window, meaning that the difference between therapeutic and toxic doses is small.

Theophylline's mechanism of action involves inhibition of phosphodiesterase, leading to an increase in cyclic AMP and resultant bronchodilation. However, due to its narrow therapeutic range, serum levels need to be maintained within 10 to 20 mcg/ml to ensure efficacy while avoiding toxicity. Levels below this range may not provide the desired therapeutic effect, whereas levels above 20 mcg/ml can lead to toxicity, which may present as nausea, vomiting, seizures, or even life-threatening arrhythmias.

Think of the therapeutic range for theophylline like the temperature range for cooking a delicate dish. Too low, and the dish won't cook properly (ineffective treatment); too high, and it will burn (toxicity). The right temperature range ensures a perfectly cooked meal, just like the right theophylline levels ensure effective and safe treatment.

Nurse Emma should regularly monitor Ms. Green's serum theophylline levels and be vigilant for any signs of toxicity. This includes educating Ms. Green about the importance of adhering to her prescribed dosage and avoiding factors that can influence theophylline levels, such as smoking or consuming certain foods and medications.

• Regularly check serum theophylline levels to ensure they are within the therapeutic range.
• Educate the patient on avoiding caffeine and other stimulants that can interact with theophylline.
• Monitor for signs of toxicity, such as nausea, vomiting, headache, and palpitations.
• Ensure the patient understands the importance of adhering to their medication regimen and not altering the dose without consulting their healthcare provider.

✘Incorrect answer options:

1 to 2 mcg/ml. This range is far below the therapeutic range and would be ineffective in achieving the desired bronchodilation.

2 to 5 mcg/ml. Similar to the 1 to 2 mcg/ml range, this concentration is too low to provide therapeutic benefits for asthma management.

5 to 10 mcg/ml. Although higher than the previous ranges, 5 to 10 mcg/ml is still below the therapeutic range for theophylline. This level might not be sufficient to achieve optimal bronchodilation and control asthma symptoms.

EXPLANATION

✔Correct answer:

Ensuring his airway remains patent. The first priority in caring for a patient with a newly placed tracheostomy is ensuring that the airway remains patent (open). A patent airway is critical for adequate oxygenation and ventilation. The tracheostomy tube provides a direct route for air to enter the lungs, and any obstruction or complication can lead to severe respiratory distress or failure.

A tracheostomy bypasses the upper airway, creating an alternative path for breathing. This procedure is typically performed to relieve airway obstruction, provide long-term mechanical ventilation, or manage secretions. Ensuring the tracheostomy tube is clear and functional is crucial because any blockage can immediately impact the patient’s ability to breathe.

Think of the tracheostomy tube like a straw in a drink. If the straw gets blocked, it becomes impossible to drink. Similarly, if the tracheostomy tube gets blocked, the patient cannot breathe effectively.

Nurse Williams should focus on the following actions to ensure the airway remains patent:

• Regularly assess the tracheostomy site and tube for signs of obstruction, such as mucus build-up or displacement.
• Suction the tracheostomy tube as needed to remove secretions that could block the airway.
• Ensure the tracheostomy tube is securely in place and the ties are not too tight or too loose.
• Monitor Mr. Johnson’s respiratory rate, oxygen saturation, and overall breathing effort frequently.
• Keep emergency equipment, such as a spare tracheostomy tube and suction apparatus, readily available at the bedside.

✘Incorrect answer options:

Assisting him with communication. While assisting with communication is important for a patient with a tracheostomy, it is not the immediate first priority. Ensuring the airway is open takes precedence because it is vital for the patient’s survival.

Encouraging participation in daily activities. Encouraging participation in daily activities is part of the overall care plan but is not the immediate first priority. Maintaining a patent airway is critical before focusing on other aspects of care.

Preventing infection. Preventing infection is also crucial in the care of a patient with a tracheostomy, as infections can complicate recovery. However, ensuring the airway remains patent is the most immediate concern, as any blockage can lead to acute respiratory distress.

EXPLANATION

✔Correct answer:

Performing endotracheal suctioning. Endotracheal suctioning is a common procedure performed to clear secretions from the airway of patients with a tracheostomy. However, this intervention can temporarily decrease arterial blood oxygen saturation. The suctioning process can induce hypoxia because it removes not only secretions but also air from the airway, which can cause a drop in oxygen levels. Additionally, the suctioning procedure can induce coughing, bronchospasm, or even temporary airway occlusion, all of which can contribute to decreased oxygenation.

During suctioning, the catheter may block the airway partially or completely, preventing adequate ventilation. This can lead to a temporary decrease in the amount of oxygen that reaches the alveoli, thus reducing gas exchange and leading to a drop in arterial oxygen saturation. The body's response to suctioning can also include a stress reaction, leading to increased metabolic demand and, consequently, higher oxygen consumption.

Imagine trying to drink water through a straw while someone intermittently pinches the straw closed. The intermittent closure (suctioning) disrupts the flow of water (air) and makes it difficult to drink (breathe), leading to temporary periods where you can't get enough water (oxygen).

Nurses should ensure to pre-oxygenate the patient before suctioning and use appropriate suctioning techniques to minimize the duration and frequency of suctioning. Monitoring the patient's oxygen saturation before, during, and after the procedure is crucial to quickly address any significant drops in oxygen levels.

• Pre-oxygenate the patient with 100% oxygen for a short period before suctioning.
• Limit each suctioning pass to 10-15 seconds to minimize hypoxia.
• Use the lowest effective suction pressure to avoid mucosal damage and excessive removal of air.
• Monitor the patient's oxygen saturation continuously during the procedure.
• Re-oxygenate the patient between suctioning passes if multiple passes are necessary.

✘Incorrect answer options:

Encouraging the patient to cough. Encouraging coughing can help clear secretions and improve oxygenation. While coughing may be temporarily uncomfortable or increase metabolic demand slightly, it generally helps to maintain or even improve oxygen saturation by clearing obstructive secretions from the airway.

Applying a cooling blanket. Using a cooling blanket is aimed at reducing fever and would not directly impact arterial blood oxygen saturation. It helps in managing hyperthermia and can improve patient comfort and reduce metabolic demand, which might indirectly support better oxygenation.

Using incentive spirometry. Incentive spirometry encourages deep breathing and lung expansion, which helps improve ventilation and oxygenation. This intervention is designed to increase lung volumes, reduce atelectasis, and improve oxygen saturation, not decrease it.

EXPLANATION

✔Correct answer:

Submerge the end of the chest tube in a container filled with sterile saline. If a chest tube becomes disconnected from the drainage system, the primary concern is to prevent air from entering the pleural cavity, which can lead to a pneumothorax or worsen an existing one. Submerging the end of the chest tube in a container filled with sterile saline creates a water seal that prevents air from entering the pleural space, thereby maintaining the negative pressure and preventing further complications.

The chest tube is placed to drain air, blood, or fluid from the pleural space, helping to re-establish normal intrapleural pressure and allowing the lung to expand. If the system is disconnected, air can enter the pleural space, disrupting this balance and potentially causing a tension pneumothorax, which is a life-threatening condition.

Imagine you have a straw submerged in a glass of water (representing the chest tube in the pleural space). If you pull the straw out of the water but leave the top open, air can enter the straw. But if you place the straw back into the water, air is prevented from entering and the system remains sealed.

Nurse Patel should act quickly to submerge the disconnected chest tube end in sterile saline, thereby preventing air entry. She should then:

• Notify the physician of the disconnection and the measures taken.
• Prepare for potential reconnection to a new drainage system or further medical intervention as directed by the physician.
• Continuously monitor the patient's respiratory status and vital signs for any signs of respiratory distress.
• Ensure that the chest tube connections are secure to prevent future disconnections.

✘Incorrect answer options:

Cover the end with an occlusive dressing and notify the physician. Covering the chest tube with an occlusive dressing without addressing the need to prevent air from entering the pleural space can lead to the development of a tension pneumothorax. This option does not provide an immediate solution to maintaining the necessary water seal.

Immediately clamp the chest tube. Clamping the chest tube can be dangerous as it can lead to a rapid accumulation of air in the pleural space, causing a tension pneumothorax. Clamping is generally avoided unless specifically instructed by a physician and in very controlled situations.

Secure the chest tube with adhesive tape. Simply securing the tube with adhesive tape does not address the critical issue of preventing air from entering the pleural space. This action does not provide the immediate protective measure required in this emergency situation.

EXPLANATION

✔Correct answer:

Instruct the client to breathe into a paper bag. Mr. Peterson's ABG results indicate respiratory alkalosis, as evidenced by a pH of 7.5 (above the normal range of 7.35-7.45) and a PaCO2 of 26 mm Hg (below the normal range of 35-45 mm Hg). The normal HCO3 level (24 mEq/L) suggests that the alkalosis is not metabolic but rather due to hyperventilation, leading to excessive CO2 loss.

Respiratory alkalosis occurs when there is excessive ventilation, causing a significant decrease in PaCO2 (carbon dioxide). The body attempts to compensate for this by reducing the respiratory rate or depth. Breathing into a paper bag helps increase the CO2 levels by having the patient re-inhale the exhaled CO2, thus helping to correct the alkalosis.

Think of the body's CO2 levels like the thermostat in a house. If the thermostat is set too low (hyperventilation), the house becomes too cold (low CO2 levels, leading to alkalosis). Breathing into a paper bag is like turning up the thermostat, allowing the house to warm up to a comfortable level (increasing CO2 to restore pH balance).

Nurse Laura should instruct Mr. Peterson to breathe into a paper bag for short periods to increase CO2 levels and help normalize the pH. Additionally, she should monitor the patient's respiratory status and reassess the ABG values after the intervention.

✘Incorrect answer options:

Administer a prescribed decongestant. A decongestant is not appropriate for treating respiratory alkalosis. It is used to relieve nasal congestion but does not address the underlying issue of hyperventilation and CO2 loss.

Offer the client fluids frequently. While hydration is important for overall health, it does not directly address the issue of respiratory alkalosis caused by hyperventilation.

Administer prescribed supplemental oxygen. Administering supplemental oxygen is not necessary, as Mr. Peterson's O2 saturation is 96% and his PaO2 is 94 mm Hg, both of which are within normal ranges. Oxygen administration would not correct the underlying problem of hyperventilation and may even exacerbate it.

EXPLANATION

✔Correct answer:

Impaired gas exchange related to airflow obstruction. In patients with chronic obstructive pulmonary disease (COPD), the primary issue is impaired gas exchange due to airflow obstruction. This obstruction is caused by inflammation and narrowing of the airways, mucus production, and loss of elastic recoil in the alveoli. The most crucial nursing diagnosis for Mr. Green is therefore impaired gas exchange, as this directly impacts his oxygenation and carbon dioxide elimination, which are vital for life.

COPD includes chronic bronchitis and emphysema, both of which contribute to airflow obstruction. This obstruction leads to difficulties in ventilating the alveoli, resulting in decreased oxygen uptake and carbon dioxide elimination. Over time, this can cause hypoxemia (low blood oxygen) and hypercapnia (high blood carbon dioxide), which are life-threatening if not managed appropriately.

Imagine a balloon with a narrow, partially blocked opening. It’s hard to blow air into the balloon and even harder for air to escape, making it difficult to keep the balloon properly inflated. Similarly, in COPD, the airways are narrowed and obstructed, making it challenging for air to move in and out of the lungs, leading to impaired gas exchange.

Nurse Daniels should focus on interventions that improve Mr. Green’s gas exchange:

• Monitor respiratory rate, rhythm, and effort, as well as oxygen saturation levels.
• Administer prescribed bronchodilators, corticosteroids, and other medications to reduce airway inflammation and obstruction.
• Position Mr. Green in a semi-Fowler’s or high-Fowler’s position to facilitate easier breathing.
• Encourage and assist with breathing exercises, such as pursed-lip breathing, to improve ventilation.
• Provide supplemental oxygen as prescribed, ensuring careful monitoring to avoid oxygen-induced hypercapnia.
• Encourage adequate hydration to help thin mucus secretions and promote their clearance.

✘Incorrect answer options:

Activity intolerance related to fatigue. While activity intolerance is a significant issue for COPD patients, it is secondary to the primary problem of impaired gas exchange. Addressing gas exchange will help improve activity tolerance.

Anxiety related to actual threat to health status. Anxiety is common in COPD patients due to their breathing difficulties and the chronic nature of the disease. However, it is not as immediately life-threatening as impaired gas exchange and thus is a lower priority.

Risk for infection related to retained secretions. COPD patients are at increased risk for respiratory infections due to mucus retention. However, preventing infections, while important, is not as critical as addressing impaired gas exchange, which has a more immediate impact on the patient’s survival.

EXPLANATION

✔Correct answer:

0.5. The goal of mechanical ventilation is to provide adequate oxygenation while minimizing the risk of oxygen toxicity. Prolonged exposure to high concentrations of oxygen (greater than 0.5 or 50%) can lead to oxygen toxicity, which can cause damage to lung tissues. Therefore, it is important to reduce the fraction of inspired oxygen (FIO2) to the lowest level that maintains adequate oxygenation.

Oxygen toxicity results from the harmful effects of breathing molecular oxygen (O2) at increased partial pressures. It can lead to oxidative stress and damage to the alveolar-capillary membrane, resulting in conditions like acute respiratory distress syndrome (ARDS) and decreased lung compliance.

Think of high FIO2 like a powerful flashlight. If you shine it on an object for too long, it can cause damage to the object. Similarly, high oxygen levels for a prolonged period can damage lung tissues.

Nurse Stevens should monitor John’s oxygenation status and adjust the FIO2 accordingly. The target FIO2 should be reduced to 0.5 or 50% as soon as it is feasible, based on John's oxygen saturation (SaO2) and partial pressure of arterial oxygen (PaO2) levels, ensuring they remain within acceptable ranges (PaO2 of 60-100 mm Hg and SaO2 above 90%).

✘Incorrect answer options:

0.21. This is the FIO2 of room air (21%). While reducing FIO2 to room air is the ultimate goal for weaning off oxygen therapy, it is not realistic to drop from 0.9 to 0.21 immediately. The reduction should be gradual to ensure adequate oxygenation.

0.35. Although lower than 0.5, this option might not be sufficient to maintain adequate oxygenation in a patient with respiratory failure and pneumonia. The reduction should be safe and not compromise oxygenation.

0.7. This is still a relatively high concentration of oxygen. While safer than 0.9, it is higher than the recommended target of 0.5 to minimize the risk of oxygen toxicity.

EXPLANATION

✔Correct answer:

Hypotension. Hypotension, or low blood pressure, can significantly alter pulse oximetry readings. Pulse oximetry relies on the detection of blood flow through the tissues to measure oxygen saturation. If a patient is experiencing hypotension, the peripheral perfusion (blood flow to the extremities) can be decreased. This reduction in blood flow can make it difficult for the pulse oximeter to obtain an accurate reading, leading to potentially unreliable or falsely low oxygen saturation values.

Hypotension can result from various conditions such as shock, dehydration, or cardiac issues. When blood pressure is low, the body prioritizes perfusion to vital organs like the heart and brain, reducing blood flow to the peripheral tissues where the pulse oximeter is typically placed (e.g., fingers, toes). This decreased perfusion can interfere with the sensor’s ability to detect the pulsatile blood flow necessary for accurate measurement.

Think of pulse oximetry like a camera trying to take a clear picture in low light. If the light (blood flow) is too dim, the picture (oxygen saturation reading) will be blurry or inaccurate. Ensuring proper lighting (adequate perfusion) is crucial for a clear picture.

Nurse Blake should take the following actions to ensure accurate monitoring of Ms. Roberts's oxygen saturation:

• Regularly assess Ms. Roberts’s blood pressure and ensure it is within a normal range to maintain adequate peripheral perfusion.
• If hypotension is detected, address the underlying cause and consider using alternative sites for pulse oximetry (e.g., earlobe or forehead) that may provide more reliable readings in cases of poor peripheral perfusion.
• Monitor other indicators of oxygenation, such as arterial blood gas (ABG) analysis, which can provide more accurate measurements of oxygenation status.
• Ensure the pulse oximeter probe is properly placed and not affected by external factors such as patient movement, ambient light, or nail polish.

✘Incorrect answer options:

Fever Fever can increase metabolic demands and oxygen consumption, but it does not typically interfere directly with the pulse oximetry readings. However, the increased metabolic rate and associated symptoms should still be monitored and managed.

Tachypnea Tachypnea, or rapid breathing, may indicate respiratory distress, but it does not directly affect the accuracy of pulse oximetry readings. It is crucial to address the underlying cause of tachypnea, but it does not interfere with the pulse oximeter’s ability to measure oxygen saturation.

Tachycardia Tachycardia, or a rapid heart rate, is a sign of increased cardiovascular activity, but it does not directly impact the accuracy of pulse oximetry readings. While it is essential to manage the underlying cause of tachycardia, the pulse oximeter can still provide accurate oxygen saturation readings.

EXPLANATION

✔Correct answer:

Acute adrenocortical insufficiency. Prednisone is a corticosteroid that mimics the effects of cortisol, a hormone produced by the adrenal glands. When taken for an extended period, prednisone can suppress the natural production of cortisol by the adrenal glands. If Ms. Carter abruptly stops taking prednisone, her body may not have sufficient time to resume normal cortisol production, leading to acute adrenocortical insufficiency (also known as adrenal crisis). This condition is characterized by symptoms such as fatigue, weakness, nausea, vomiting, low blood pressure, and in severe cases, can be life-threatening.

The hypothalamic-pituitary-adrenal (HPA) axis regulates cortisol production. Long-term use of corticosteroids like prednisone suppresses this axis. Sudden discontinuation of the medication doesn't give the adrenal glands enough time to resume adequate cortisol production, resulting in a deficiency that can lead to acute adrenocortical insufficiency.

Imagine if a factory stops producing its own goods because it's importing the same goods from elsewhere. If the imports suddenly stop, the factory can't immediately resume production, leading to a shortage. Similarly, the adrenal glands can't quickly start producing cortisol if prednisone is abruptly stopped, leading to a hormone deficiency.

Nurse Thompson should educate Ms. Carter on the importance of tapering off prednisone gradually, as prescribed by her healthcare provider, to allow her adrenal glands time to adjust and start producing cortisol naturally again.

• Explain the signs and symptoms of acute adrenocortical insufficiency to Ms. Carter so she can recognize them and seek immediate medical help if necessary.
• Reinforce the necessity of following the prescribed tapering schedule strictly.
• Ensure Ms. Carter understands the potential risks of abruptly stopping the medication.
• Encourage regular follow-up appointments to monitor her condition and adjust the medication regimen as needed.

✘Incorrect answer options:

Hyperglycemia and glycosuria Hyperglycemia (high blood sugar) and glycosuria (glucose in the urine) are potential side effects of corticosteroid use, but they are not caused by abrupt discontinuation. These conditions are related to the medication's effects on glucose metabolism.

Gastrointestinal bleeding Gastrointestinal bleeding can be a side effect of long-term corticosteroid use due to increased risk of peptic ulcers. However, it is not specifically a consequence of abruptly stopping prednisone.

Restlessness and seizures Restlessness and seizures are not typical symptoms associated with the sudden discontinuation of corticosteroids. These symptoms are more likely related to neurological or metabolic issues not directly linked to prednisone withdrawal.

EXPLANATION

✔Correct answer:

A positive reaction shows that the client has been exposed to tuberculosis. A positive reaction to the purified protein derivative (PPD) test, also known as the Mantoux tuberculin skin test, indicates that the client has been exposed to Mycobacterium tuberculosis. This exposure has led to sensitization, meaning the person has developed an immune response to the TB bacteria. However, a positive PPD test does not confirm active TB disease. It only indicates that the person has been infected with the bacteria at some point in their life. Further evaluation, including a chest X-ray and sputum cultures, is necessary to determine if the client has active TB disease.

When a person is infected with TB bacteria, their immune system responds to the antigens in the PPD test, causing a localized skin reaction. This reaction is typically measured 48 to 72 hours after the injection. The size of the induration (raised, hardened area) at the injection site is used to interpret the test results, with different cut-off points depending on the individual's risk factors and history.

Think of the PPD test like a security alarm system. If the alarm goes off (positive reaction), it means someone has triggered it (exposure to TB bacteria). However, it doesn't tell you if the intruder is still in the house (active TB disease); further investigation is needed.

Nurse Kim should provide accurate information and follow-up instructions to the client:

• Explain that a positive PPD test indicates exposure to TB bacteria and the need for further testing to determine if there is an active infection.
• Schedule a follow-up appointment for the client to have the test site read 48 to 72 hours after the injection.
• Inform the client about the importance of additional tests, such as a chest X-ray and sputum cultures, to confirm or rule out active TB disease if the PPD test is positive.
• Educate the client on TB prevention and the importance of seeking medical care if they experience symptoms of active TB, such as a persistent cough, weight loss, night sweats, and fever.

✘Incorrect answer options:

A positive reaction confirms that the client has active tuberculosis (TB). A positive PPD test does not confirm active TB. It indicates that the person has been exposed to TB bacteria and has developed an immune response. Further diagnostic tests are needed to determine if there is active disease.

A negative reaction always rules out the possibility of TB. A negative PPD test does not always rule out TB, especially in individuals with weakened immune systems, such as those with HIV or who are severely malnourished. These individuals may not mount a strong enough immune response to the test, resulting in a false-negative result.

The PPD results can be read within 12 hours after the injection. PPD test results should be read 48 to 72 hours after the injection. Reading the test too early can lead to inaccurate results as the immune response may not have fully developed.

EXPLANATION

✔Correct answer:

pH 7.25; PaCO2 50 mm Hg. Respiratory acidosis occurs when there is a decrease in alveolar ventilation, leading to an accumulation of carbon dioxide (PaCO2) in the blood. This results in a decrease in blood pH. The correct set of ABG values indicative of respiratory acidosis is a pH of 7.25 (which is below the normal range of 7.35-7.45) and a PaCO2 of 50 mm Hg (which is above the normal range of 35-45 mm Hg). These values confirm that the blood is more acidic due to the buildup of CO2.

In Guillain-Barré syndrome, muscle weakness, including the muscles responsible for breathing, can impair ventilation. This leads to hypoventilation and subsequent retention of CO2, causing the blood pH to drop and resulting in respiratory acidosis.

Imagine a room with a fireplace (representing the lungs). If the chimney (representing the airways) is partially blocked, smoke (representing CO2) builds up in the room, making the air unhealthy to breathe (lowering the pH). To clear the smoke, the chimney needs to be unblocked (improving ventilation).

Nurse Smith should focus on interventions to improve Mr. Rodriguez's ventilation:

• Monitor respiratory rate, depth, and effort closely.
• Assist with measures to improve ventilation, such as positioning, breathing exercises, and use of non-invasive ventilation support like CPAP or BiPAP if needed.
• Administer prescribed medications to alleviate symptoms and support respiratory function.
• Prepare for potential mechanical ventilation if respiratory function continues to decline.
• Continuously monitor ABG values to assess the effectiveness of interventions and make necessary adjustments.

✘Incorrect answer options:

pH 5.0; PaCO2 30 mm Hg A pH of 5.0 is not compatible with life and is far below the physiological range for blood pH (7.35-7.45). Additionally, a PaCO2 of 30 mm Hg is below the normal range and suggests respiratory alkalosis, not acidosis.

pH 7.40; PaCO2 35 mm Hg These values are within the normal range for both pH (7.35-7.45) and PaCO2 (35-45 mm Hg). They do not indicate any form of acidosis or alkalosis.

pH 7.35; PaCO2 40 mm Hg These values are also within the normal range, indicating neither acidosis nor alkalosis. The pH of 7.35 is at the lower end of the normal range, but still not indicative of respiratory acidosis.

EXPLANATION

✔Correct answer:

At least 2 hours post-meal. Chest physiotherapy (CPT) for patients with cystic fibrosis, which includes techniques like percussion, vibration, and postural drainage, is best scheduled at least 2 hours after meals. This timing helps to avoid inducing nausea or vomiting, which can occur if the stomach is full. Performing CPT on an empty stomach reduces the risk of aspiration and makes the patient more comfortable during the procedure.

Cystic fibrosis is characterized by the production of thick, sticky mucus that can clog the airways and lead to respiratory infections. CPT helps to mobilize and clear these secretions from the lungs, improving airway clearance and respiratory function. Scheduling CPT at least 2 hours after meals ensures that the patient is less likely to experience discomfort or complications related to gastrointestinal distress during the therapy.

Think of CPT like shaking a bottle to mix its contents. If the bottle is too full, shaking it can cause the contents to spill out. Similarly, performing CPT on a full stomach can cause discomfort or even vomiting, so it’s better to wait until the stomach is relatively empty.

Nurse Adams should follow these guidelines when scheduling chest physiotherapy for Mr. Anderson:

• Plan CPT sessions at least 2 hours after meals to minimize the risk of nausea and vomiting.
• Educate Mr. Anderson about the importance of timing CPT appropriately and ensure he understands the schedule.
• Monitor Mr. Anderson for signs of distress or discomfort during and after CPT sessions.
• Coordinate with other treatments and activities to ensure optimal timing and effectiveness of CPT.

✘Incorrect answer options:

Just before a meal. Performing CPT just before a meal is not recommended because it can increase the risk of nausea, vomiting, and discomfort due to the mechanical stimulation of the chest and abdominal area.

During episodes of bronchospasms. CPT should not be performed during episodes of bronchospasms, as this can exacerbate the patient's condition and cause further respiratory distress. Bronchospasms should be treated and resolved before initiating CPT.

Once secretions have been mobilized. The purpose of CPT is to help mobilize and clear secretions. Waiting until secretions have been mobilized defeats the purpose of the therapy. CPT should be used as a proactive measure to aid in secretion clearance.

EXPLANATION

✔Correct answer:

A respiratory rate of 22 breaths per minute. Albuterol (Proventil) is a bronchodilator commonly used to treat respiratory conditions like emphysema by relaxing the muscles around the airways and increasing airflow to the lungs. The primary therapeutic response to albuterol is improved ventilation, which can be indicated by a more normalized respiratory rate. A respiratory rate of 22 breaths per minute suggests that the medication is helping Mr. Johnson breathe more effectively.

Emphysema, a type of chronic obstructive pulmonary disease (COPD), is characterized by damage to the alveoli, leading to reduced gas exchange and difficulty in breathing. Albuterol works by stimulating beta-2 adrenergic receptors in the lungs, leading to bronchodilation, decreased airway resistance, and improved airflow.

Imagine trying to blow air through a partially blocked straw (representing narrowed airways in emphysema). Using albuterol is like widening the straw, making it easier to blow air through it and improving overall airflow.

Nurse Taylor should continue to monitor Mr. Johnson's respiratory status and look for signs of improved breathing:

• Assess respiratory rate and effort regularly to ensure the patient is not experiencing respiratory distress.
• Monitor oxygen saturation levels to confirm adequate oxygenation.
• Evaluate breath sounds to check for improved airflow and reduction in wheezing.
• Observe for any side effects of albuterol, such as tremors or tachycardia, and report them if they occur.

✘Incorrect answer options:

Pupils that are dilated and reactive to light. Pupil size and reactivity to light are not indicators of the effectiveness of albuterol. They are more relevant in assessing neurological function.

A urine output of 40 mL per hour. While this indicates normal kidney function, it is not a measure of the therapeutic response to albuterol, which is focused on respiratory improvement.

A heart rate of 100 beats per minute. An increased heart rate (tachycardia) can be a side effect of albuterol, rather than a therapeutic response. Although tachycardia can occur, it is not used to determine the effectiveness of the medication in improving respiratory function.

EXPLANATION

✔Correct answer:

Measure and record the amount of drainage in the collection chamber. Monitoring and documenting the amount of drainage from a chest tube is a critical aspect of patient care. This information helps to assess the patient’s condition, detect any significant changes, and ensure the chest tube is functioning properly. Consistent measurement and recording provide valuable data that can indicate complications such as increased bleeding or changes in pleural fluid.

The chest tube allows for the removal of air, blood, or fluid from the pleural space, which helps re-expand the lung and restore normal intrapleural pressure. Accurate measurement of drainage ensures that the system is effectively removing these substances and helps to detect any abnormalities in the patient’s recovery process.

Think of the chest tube drainage system like a rain gauge measuring how much rain has fallen. Just as the gauge helps you understand the weather conditions, the drainage measurements help healthcare providers understand what’s happening inside the patient’s chest.

Nurses should frequently monitor the chest tube and drainage system, ensure the tube remains patent, and document the amount and characteristics of the drainage accurately. This helps in early detection of complications and appropriate interventions.

• Measure and record the amount and type of drainage at regular intervals as per hospital protocol.
• Check the chest tube system for any signs of malfunction or disconnection.
• Ensure the chest tube remains securely in place and is not kinked or blocked.
• Educate the patient about the purpose of the chest tube and the importance of not manipulating it.

✘Incorrect answer options:

Ensure there is continuous bubbling in the water-seal chamber. Continuous bubbling in the water-seal chamber indicates an air leak, which is not a normal finding and requires investigation. Gentle bubbling during expiration or coughing can be normal, but continuous bubbling suggests a problem that needs to be addressed.

Position the collection chamber at chest level. The collection chamber should be placed below the level of the chest to facilitate proper drainage by gravity. Positioning it at chest level can hinder drainage and increase the risk of complications.

Strip the chest tube every hour. Stripping the chest tube, which involves compressing the tube to clear clots, is not recommended as a routine practice due to the potential to create excessive negative pressure and damage the pleura. This practice can cause trauma to the pleural tissue and is generally avoided.

EXPLANATION

✔Correct answer:

The mucous membranes. In clients with dark skin, signs of cyanosis can be more difficult to detect due to the increased pigmentation. Therefore, it is most accurate to assess areas where the skin is thinner and less pigmented, such as the mucous membranes, to observe for bluish discoloration indicative of cyanosis. The mucous membranes of the mouth, especially the gums and inner lips, provide a clearer indication of oxygenation status.

Cyanosis occurs when there is insufficient oxygen in the blood, leading to a bluish coloration of the skin and mucous membranes. This is more easily observed in areas with less pigmentation and where the blood vessels are closer to the surface. For individuals with darker skin, examining the mucous membranes provides a more reliable assessment of cyanosis compared to other areas like the lips, nail beds, or earlobes.

Checking for cyanosis in dark-skinned individuals is like looking for a shadow in a dark room. It’s easier to see the shadow in areas with more light (thinner, less pigmented skin) than in areas already covered in darkness.

When assessing for cyanosis in clients with dark skin, nurses should focus on the mucous membranes and other less pigmented areas. This includes careful examination of the oral cavity, as well as considering other clinical signs and symptoms of hypoxia, such as changes in mental status, breathing patterns, and the use of accessory muscles.

• Inspect the mucous membranes of the mouth, particularly the gums and inner lips, for bluish discoloration.
• Observe other signs of hypoxia, such as increased respiratory rate, use of accessory muscles, and changes in mental status.
• Ensure adequate lighting during the assessment to improve visualization of subtle color changes.
• Use pulse oximetry to objectively measure oxygen saturation and correlate with physical assessment findings.

✘Incorrect answer options:

The lips. Although the lips can show signs of cyanosis, in individuals with dark skin, the increased pigmentation may make it difficult to accurately assess color changes. The mucous membranes are more reliable for this purpose.

The nail beds. The nail beds can also indicate cyanosis, but like the lips, increased pigmentation in dark-skinned individuals can obscure the bluish discoloration. Additionally, nail polish or other factors can interfere with this assessment.

The earlobes. The earlobes are not the best site for assessing cyanosis, as they do not provide a clear view of blood vessel changes and are also more pigmented in dark-skinned individuals. The mucous membranes offer a better assessment site for detecting cyanosis.

EXPLANATION

✔Correct answer:

Tidal volume. Tidal volume (TV) is the amount of air that is inspired and expired with each normal breath. It is a key component in assessing respiratory function and is essential for maintaining adequate gas exchange in the lungs.

Tidal volume represents the volume of air moved in and out of the lungs during a normal, quiet breath. It typically averages around 500 mL in a healthy adult. This volume ensures that there is enough air to support the body's oxygen needs and to remove carbon dioxide produced by cellular metabolism.

Think of tidal volume like the gentle waves on a beach, where each wave represents a breath bringing in and expelling a consistent, small amount of water (air) with each movement.

Nurse Taylor can reinforce the understanding of tidal volume by explaining its importance in clinical settings, such as monitoring ventilator settings for patients requiring mechanical ventilation or assessing respiratory health in patients with conditions like COPD or asthma.

✘Incorrect answer options:

Residual volume. Residual volume (RV) is the amount of air remaining in the lungs after a forceful expiration. This volume ensures that the lungs do not collapse and that gas exchange can continue between breaths.

Vital capacity. Vital capacity (VC) is the maximum amount of air that can be exhaled after a maximum inhalation. It includes the tidal volume, inspiratory reserve volume, and expiratory reserve volume and is a measure of the functional capacity of the lungs.

Dead-space volume. Dead-space volume refers to the portion of the respiratory system where air is present but no gas exchange occurs, such as in the trachea and bronchi. This volume does not contribute to oxygenation of the blood.

EXPLANATION

✔Correct answer:

Baseline arterial blood gas (ABG) levels. Baseline arterial blood gas (ABG) levels are the most crucial assessment parameter for Nurse Emily to review when preparing to wean Mr. Thompson from a ventilator. ABG levels provide vital information about the patient's respiratory function, including oxygenation, carbon dioxide levels, and acid-base balance. These parameters are essential to determine if Mr. Thompson's respiratory system can adequately support spontaneous breathing without the assistance of mechanical ventilation.

Weaning a patient from a ventilator involves gradually reducing the support provided by the ventilator to allow the patient's respiratory muscles to take over. ABG levels help assess the patient's ability to maintain adequate gas exchange and acid-base balance during this process. For successful weaning, the patient should have stable and acceptable ABG values indicating effective respiratory function.

Think of ABG levels like the health indicators on a dashboard of a car. Just as you would check the car's fuel, oil, and engine status before a long trip, you need to check the patient's ABG levels to ensure their respiratory system is ready for the weaning process.

Nurse Emily should review Mr. Thompson's ABG levels to ensure they are within acceptable ranges before initiating the weaning process. She should monitor the following parameters:

• PaO2: Partial pressure of oxygen in arterial blood, indicating oxygenation status.
• PaCO2: Partial pressure of carbon dioxide in arterial blood, indicating ventilation efficiency.
• pH: Acid-base balance, indicating overall metabolic status.
• HCO3-: Bicarbonate levels, indicating metabolic compensation.

✘Incorrect answer options:

Fluid intake over the last 24 hours. While fluid balance is important for overall health, it is not the most crucial parameter for assessing readiness for ventilator weaning. It does not directly indicate the patient’s respiratory function or ability to maintain adequate gas exchange.

Previous weaning outcomes. Previous weaning outcomes provide useful historical information but do not reflect the current physiological status of the patient. ABG levels provide real-time data on the patient's respiratory status.

Electrocardiogram (ECG) results. ECG results are important for monitoring cardiac function but do not directly assess respiratory function or readiness for ventilator weaning. ABG levels are more directly related to the patient's ability to breathe independently.

EXPLANATION

✔Correct answer:

A non-rebreather oxygen mask. Mr. Lee's arterial oxygen saturation of 88% indicates significant hypoxemia, which requires immediate and high-concentration oxygen delivery to quickly raise his oxygen levels. A non-rebreather oxygen mask can deliver high concentrations of oxygen (close to 100%) by using a reservoir bag filled with pure oxygen. It also has one-way valves that prevent the patient from rebreathing exhaled air, ensuring that the highest possible concentration of oxygen is delivered.

Hypoxemia occurs when the arterial oxygen level is below normal, leading to insufficient oxygen supply to the tissues. In acute situations where rapid improvement of oxygenation is needed, delivering high concentrations of oxygen is essential to prevent hypoxic injury to vital organs.

Think of the non-rebreather mask like a fire hose delivering water directly to a fire. Just as a fire hose delivers a large volume of water quickly to extinguish the fire, the non-rebreather mask delivers a high concentration of oxygen quickly to alleviate hypoxemia.

Nurse Johnson should take the following steps to address Mr. Lee's hypoxemia:

• Immediately apply the non-rebreather oxygen mask to deliver high-concentration oxygen.
• Ensure that the reservoir bag is inflated before placing the mask on the patient to guarantee the delivery of high oxygen concentrations.
• Monitor Mr. Lee's oxygen saturation continuously to assess the effectiveness of the intervention.
• Observe for signs of improvement in breathing, such as reduced respiratory distress and increased oxygen saturation levels.
• Be prepared to escalate care if there is no improvement, including notifying the healthcare provider and considering advanced respiratory support if needed.

✘Incorrect answer options:

A standard simple mask. While a simple mask can deliver higher oxygen concentrations than a nasal cannula (approximately 40-60% oxygen), it is not as effective as a non-rebreather mask for delivering the high concentrations of oxygen needed in this acute situation.

A face tent apparatus. A face tent is used for patients who cannot tolerate masks that fit tightly over their face, and it provides less precise oxygen delivery. It is typically used for less acute situations or for patients with facial trauma or burns.

A nasal cannula device. A nasal cannula delivers low to moderate concentrations of oxygen (up to about 44%). In the case of severe hypoxemia, such as Mr. Lee's situation, a nasal cannula would not provide a high enough concentration of oxygen to rapidly improve his oxygen saturation.

EXPLANATION

✔Correct answer:

Instructing the client on performing controlled coughing techniques. For a patient with chronic obstructive pulmonary disease (COPD), one of the most effective nursing interventions to help maintain a patent airway is teaching the patient controlled coughing techniques. Controlled coughing helps to clear mucus from the airways, which can improve breathing and reduce the risk of infection.

COPD is characterized by chronic inflammation of the airways, increased mucus production, and airway obstruction. Clearing mucus is essential to maintaining an open airway and preventing exacerbations. Controlled coughing techniques, such as huff coughing, help mobilize and expel mucus effectively without causing excessive strain.

Think of controlled coughing like using a plunger to clear a clogged drain. Just as the plunger helps to dislodge and remove the blockage, controlled coughing techniques help to expel mucus and keep the airways clear.

Nurse Davis should instruct Mr. Harris on the following controlled coughing techniques:

• Sit upright: Positioning helps expand the lungs and makes coughing more effective.
• Deep breath: Instruct the patient to take a slow, deep breath to fill the lungs.
• Huff cough: Have the patient exhale forcefully with an open mouth, saying "huff." This helps to move mucus into the larger airways where it can be expelled.
• Cough: Follow the huff with a strong, effective cough to expel the mucus.
• Hydration: Encourage adequate fluid intake to help thin mucus, making it easier to clear.

✘Incorrect answer options:

Limiting fluid intake to 1,000 ml/day. Limiting fluid intake can actually worsen mucus production by making it thicker and harder to clear, which can obstruct the airways further.

Enforcing strict bed rest. Bed rest can lead to decreased lung expansion and mucus stasis, which increases the risk of atelectasis and infection. Encouraging mobility and positioning changes is more beneficial.

Regularly administering large doses of prescribed sedatives. Sedatives can depress the respiratory system, reduce the patient's drive to breathe, and hinder effective coughing, all of which can exacerbate airway obstruction in COPD patients.