Sas 6

Case Study

1. Low-flow oxygen; calcium-channel blocking agents (nifedipine [Adalat],

diltiazem [Cardizem]), prostacyclins (epoprostenol [Flolan], bosentan
[Tracleer]), diuretics
2. Yes, because her medical treatment has failed, and she can be potentially
treated with either a lung or heart-lung transplant. She meets additional
criteria of being less than 60 years old and a nonsmoker.
3. A heart-lung transplant is indicated for the patient because she has heart
damage from the pulmonary hypertension, although there is evidence that
even a single-lung transplant can markedly correct pulmonary hypertension
and the resultant cor pulmonale.
4. Ability to cope with the postoperative regimen that includes the following: •
Strict adherence to immunosuppressive drugs • Continuous monitoring and
reporting of
manifestations of infection • Financial resources for the procedure, drugs, and
follow-up care • Social and emotional support system because she is
a single mother 
5. Nursing diagnoses:
• Activity intolerance related to fatigue as a result of hypoxemia
• Excess fluid volume related to pump failure • Impaired gas exchange related
to mechanical failure • Ineffective role performance related to inability to
perform role responsibilities • Anxiety related to breathlessness • Risk for
impaired skin integrity related to edema Collaborative problems: Potential
complications: dysrhythmias; hypoxemia

1. To evaluate the effectiveness of prescribed therapies for a patient with

ventilatory failure, which diagnostic test will be most useful to the nurse?
a. Chest x-rays
b. Pulse oximetry
c. Arterial blood gas (ABG) analysis
d. Pulmonary artery pressure monitoring
ANS: C
ABG analysis is most useful in this setting because ventilatory failure causes
problems with CO2 retention, and ABGs provide information about the
PaCO2 and pH. The other tests also may be done to help in assessing
oxygenation or determining the cause of the patient's ventilatory failure.

2. While caring for a patient who has been

admitted with a pulmonary embolism, the
nurse notes a change in the patient's oxygen
saturation (SpO2) from 94% to 88%. The nurse
will
a. increases the oxygen flow rate.
b. suction the patient's oropharynx.
c. assists the patient to cough and deep
breathe.
d. helps the patient to sit in a more upright
position.
Increasing oxygen flow rate usually will improve oxygen saturation in patients
with ventilation-perfusion mismatch, as occurs with pulmonary embolism.
Because the problem is with perfusion, actions that improve ventilation, such
as deep-breathing and coughing, sitting upright, and suctioning, are not likely
to improve oxygenation.

3. A patient with respiratory failure has a respiratory rate of 8 and an SpO2 of

89%. The patient is increasingly lethargic. The nurse will anticipate assisting
with
a. administration of 100% oxygen by nonrebreather mask.
b. endotracheal intubation and positive
pressure ventilation.
c. insertion of a mini-tracheostomy with frequent suctioning.
d. initiation of bilevel positive pressure
ventilation (BiPAP).
ANS: B
The patient's lethargy, low respiratory rate, and SpO2 indicate the need for
mechanical ventilation with ventilator-controlled respiratory rate.
Administration of high flow oxygen will not be helpful because the patient's
respiratory rate is so low. Insertion of a mini-tracheostomy will facilitate
removal of secretions, but it will not improve the patient's respiratory rate or
oxygenation. BiPAP requires that the patient initiate an adequate respiratory
rate to allow adequate gas exchange.

4. When admitting a patient in possible

respiratory failure with a high PaCO2, which assessment information will be
of most concern to the nurse?
a. The patient is somnolent.
b. The patient's SpO2 is 90%.
c. The patient complains of weakness.
d. The patient's blood pressure is 162/94.
ANS: A
Increasing somnolence will decrease the patient's respiratory rate and further
increase the PaCO2 and respiratory failure. Rapid action is needed to prevent
respiratory arrest. An SpO2 of 90%, weakness, and elevated blood pressure all
require ongoing monitoring but are not indicators of possible impending
respiratory arrest.

5. A nurse answers a call light and finds a client anxious, short of breath,
reporting chest pain, and having a blood pressure of 88/52 mm Hg
on the cardiac monitor. What action by the nurse takes priority?
a. Assess the client’s lung sounds.
b. Notify the Rapid Response Team.
c. Provide reassurance to the client.
d. Take a full set of vital signs.
This client has manifestations of a pulmonary embolism, and the most critical
action is to notify the Rapid Response Team for speedy diagnosis and
treatment. The other actions are appropriate also but are not the priority.

6. A client is admitted with a pulmonary

embolism (PE). The client is young, healthy,
and active and has no known risk factors for
PE. What action by the nurse is most
appropriate?
a. Encourage the client to walk 5 minutes each
hour.
b. Refer the client to smoking cessation
classes.
c. Teach the client about factor V Leiden
testing.
d. Tell the client that sometimes no cause for
disease is found.
ANS: C
Factor V Leiden is an inherited thrombophilia that can lead to abnormal
clotting events, including PE. A client with no known risk factors for this
disorder should be referred for testing. Encouraging the client to walk is
healthy, but is not related to the development of a PE in this case, nor is
smoking. Although there are cases of disease where no cause is ever found,
this assumption is premature.

7. A client has a pulmonary embolism and is

started on oxygen. The student nurse asks why
the clients oxygen saturation has not
significantly improved. What response by the
nurse is best?
a. Breathing so rapidly interferes with
oxygenation.
b. Maybe the client has respiratory distress
syndrome.
c. The blood clot interferes with perfusion in
the lungs.
d. The client needs immediate intubation and
mechanical ventilation.
A large blood clot in the lungs will significantly impair gas exchange and
oxygenation. Unless the clot is dissolved, this process will continue unabated.
Hyperventilation can interfere with oxygenation by shallow breathing, but
there is no evidence that the client is hyperventilating, and this is also not the
most precise physiologic answer. Respiratory distress syndrome can occur,
but this is not as likely. The client may need to be mechanically ventilated, but
without concrete data on FiO2 and SaO2, the nurse cannot make that
judgment.

8. A client appears dyspneic, but the oxygen saturation is 97%. What action by
the nurse is best?
a. Assess for other manifestations of hypoxia.
b. Change the sensor on the pulse oximeter.
c. Obtain a new oximeter from central supply.
d. Tell the client to take slow, deep breaths.
Pulse oximetry is not always the most accurate assessment tool for hypoxia as
many factors can interfere, producing normal or near-normal readings in the
setting of hypoxia. The nurse should conduct a more thorough assessment.
The other actions are not appropriate for a hypoxic client.

9. A nurse is assisting the health care provider

who is intubating a client. The provider has
been attempting to intubate for 40 seconds.
What action by the nurse takes priority?
a. Ensure the client has adequate sedation.
b. Find another provider to intubate.
c. Interrupt the procedure to give oxygen.
d. Monitor the client’s oxygen saturation.
Each intubation attempt should not exceed 30 seconds (15 is preferable) as it
causes hypoxia. The nurse should interrupt the intubation attempt and give
the client oxygen. The nurse should also have adequate sedation during the
procedure and monitor the clients oxygen saturation, but these do not take
priority. Finding another provider is not appropriate at this time.

10. An intubated clients oxygen saturation has

dropped to 88%. What action by the nurse
takes priority?
a. Determine if the tube is kinked.
b. Ensure all connections are patent.
c. Listen to the client’s lung sounds.
d. Suction the endotracheal tube.
When an intubated client shows signs of hypoxia, check for DOPE: displaced
tube (most common cause), obstruction (often by secretions), pneumothorax,
and equipment problems. The nurse listens for equal, bilateral breath sounds
first to determine if the endotracheal tube is still correctly placed. If this
assessment is normal, the nurse would follow the mnemonic and assess the
patency of the tube and connections and perform suction.