NR 341/ NR341 COMPLEX ADULT HEALTH EXAM 2 LATEST 2023-2024 REAL EXAM QUESTIONS AND CORRECT ANSWERS|AGRADE PDF

ABG Overview #1

(graphic #1)

ABG Overview #2

(graphic #2)

ABG Overview #3

(graphic #3)

Fully compensated:

– pH normal
– PaCO2 & HCO3 abnormal

Partially compensated:

– All values are abnormal

Uncompensated

– pH and one other value is abnormal

Measurements of Oxygenation:

– 80 – 100mmHG
– SpO2 = 92%-99%

Arterial Blood Gas Interpretation:

Alkalosis:

(see graphic)

Acidosis:

(see graphic)

Potassium Levels in Acidosis:

– K+ = Elevated

Respiratory Acidosis:

– low pH, high CO2

Respiratory Alkalosis:

– high pH, low CO2

Metabolic Acidosis:

– low pH, low HCO3

Metabolic Alkalosis:

– high pH, high HCO3

Interpret this ABG:

– ph 7.37
– PaCO2 50 mm HG
– Bicarbonate 30 mEq/L

Rescue Breathing Position:

– Side lying position

Airway Management:

– Essential nursing skills that maintain natural or artificial airways for compromised clients

NPPV Machine:

– Non Invasive Positive Pressure Ventilation

CPAP/BiPap Machine Overview:

– Indications: acute COPD, cardiogenic pulmonary edema, early hypoxemic failure in immunocompromised patients, obstructive sleep apnea, and to prevent re-intubation
– Contraindications: apnea, cardiovascular instability or hypotension, dysrhythmias, MI, claustrophobia, somnolence, high aspiration risk, copious secretions, GI surgery, craniofacial trauma, and burns

Endotracheal Intubation (ET):

– Insertion of endotracheal tube through the mouth or nose…preferred route to reduce infections
– Indications: maintain airway, remove secretions, prevention aspiration, and provide mechanical ventilation

Intubation Equipment:

– Ambu Bag connected to oxygen
– Laryngoscope & endotracheal tubes
– Suction equipment
– Ventilator
– Device or tape to secure ETT

Rapid Sequence Intubation (RSI):

– Giving medications to sedate (induce) and temporarily paralyze a patient and then performing orotracheal intubation.
– Eg. propofol, midazolam, short term paralytics, or fentanyl
– Sedate -> pain medicine -> short term paralytic

Securing ETT:

True/False: if the nurse suspects the ET tube is in the esophagus, pull out the tube and do the following…Bag-mask ventilation with an oropharyngeal or nasopharyngel or both

True, always maintain a high index of suspicion of esophageal intubation, particularly if the intubation was difficult. If in doubt, trust your instincts!!!

Tracheostomy Overview:

– Indications: Long-term mechanical ventilation, frequent suctioning, protecting the airway

Endotracheal Suctioning:

– Indicated by assessment (PRN): visible secretions, coughing, rhonchi, high pressure on vent, and ventilator alarm
– Conventional versus closed suctioning
– Procedures: hyper oxygenated throughout procedure, avoid normal saline instillation

Ventilator Settings:

– Uses positive pressure by mechanically filling the lungs with O2 and is the opposite of the physiology of breathing
– Fraction of Inspired Oxygen (FiO2); the percentage of inspired O2 the ventilator is giving the patient?
– FiO2 ranges from 0.21 (21%) to 1.0 (100%) O2. RA = 0.21 or 21% O2
– Respiratory Rate (RR) the number of breaths to be delivered to the patient per minute

Positive End Expiratory Pressure (PEEP):

– The amount of positive pressure (in cms of H20) applied to the airways during expiration; PEEP is meant to hold open the alveoli and prevent airway collapse between breaths

Positive End-Expiratory Pressure (PEEP)

PEEP

Alarms & Troubleshooting:

– NEVER shut alarms off; only silence
– Manually ventilate if unsure of the problem until a new ventilator is available for use
– Most ICUs have dedicated RTs who manage mechanical vent along with nurse and/or physician

Types of Vent Alarms:

– High Pressure: Increased secretions, wheezing, bronchospasm, causing decreased airway, displaced ETT. Pt. gag, kinked, biting
– Low Pressure: Disconnection or leak in ventilator or patient’s airway cuff; patient stops breathing

Complications of Mechanical Ventilation:

– ETT out of position…right main stem bronchus, dislodged
– Unplanned extubation…securing important
– Laryngeal / Tracheal Injury…prevent excessive head movement
– Damage to oral and nasal mucosa

Barotrauma:

– Injury caused by pressure to enclosed body surfaces, for example from too much pressure in the lungs. Eg. Pneumothorax, tension pneumothorax
– Detect: high peak airway pressures on vent, mean airway pressure, decreased breath sounds, tracheal shift, subcutaneous crepitus, and hypoxemia
– Treat tension pneumothorax via manually ventilate, needle thoracostomy

Complications of Mechanical Ventilation – Infection:

– Normal protective mechanism bypassed by ETT tube; ventilator-associated pneumonia (VAP)
– Ventilator bundle: Head of bed at 30 degrees, awaken daily and assess readiness to wean, stress ulcer prophylaxis (eg. pantoprazole), DVT prophylaxis (enoxaparin, Sequential Compression Devices), oral care using chlorohexidine in some bundles

Stopping the Weaning Process:

– RR > 35 or < 8 breaths/min
– Low spontaneous V1 < 5mL/kg
– Labored respirations
– Use of accessory muscles
– Low O2 Sat <90%
– HR or BP changes > 20% from baseline
– Dysrhythmias (eg. PVCs)
– ST-segment elevation
– Dec. LOC
– Anxiety

Extubation:

– Removal of endotracheal tube
– Assess: stridor (high-pitched whistle sound), hoarseness, change in VS, and low O2 Sat
– NPPV may prevent need for re-intubation
– Care post extubation

Respiratory Assessment:

– Cardinal signs of increased CO2/hypoxia; anxiety, restlessness (early sign), confusion
– Assess rate, depth, and pattern of respirations
– Initial response to hypoxemia are tachycardia, restlessness, anxiety..

Testing:

– Serial Chest X-ray – for improvement or worsening of condition x1 daily
– Labs – Electrolytes, H&H, and ABGs
– Pulse oximetry and end tidal CO2

Interventions of Respiratory Failure:

– Goals: maintain a patent airway, optimize O2 delivery, minimize O2 demand, treat cause of ARDS, and prevent complications
– Positioning – think High Fowler’s
– Blood transfusion may help with low Hgb
– Decrease metabolic demand (lower anxiety or administer antipyretic if indicated)

Medical Management of Respiratory Failure:

– Oxygen
-Bronchodilators
-Corticosteroids
-Transfusions

Acute Respiratory Failure in COPD – Interventions:

– Correct hypoxemia; cautious admin of O2, noninvasive positive-pressure vent, vent assistance
– O2 therapy is provided with goal of PaO2 >> 60 mmHG and SaO2 > 90%
– Common medications: Beta2Agonists (albuterol, which causes smooth muscle relaxation but can cause tachycardia), anticholinergics, corticosteroids, antibiotics

Acute Respiratory Failure – Asthma:

– Chronic inflammatory
– Asthma Exacerbation: wheezes, dyspnea, chest tightness, tachypnea, tachycardia, agitation, use of accessory muscles, and retractions
– Treatment: bronchodilators

Acute Respiratory Failure – Pneumonia:

– Types: community acquired, healthcare qcquired, or ventilator associated
– Increased risk: elderly, alcoholic, smokers, chronic diseases, head injury, and immunosuppression

Pneumonia S/S:

– Fever, cough, chills, sputum, hemoptysis, dyspnea, chest pain, tachypnea, and adventitious sounds

Ventilator Associated Pneumonia (VAP):

– a health care-acquired infection (HAI) that develops in a person requiring invasive mechanical ventilation (via endotracheal intubation or tracheotomy tube) for at least 48 hours

VAP Prevention:

– Hand washing, surveillance, ventilator bundle, prevention transmission via sterile water in circuit, drain condensate away from patient, and avoid normal saline during suctioning

Pulmonary Embolism (PE):

– Virchow’s triad: venous stasis, altered coagulability, and damage to vessel wall
– Embolus results in a lack of perfusion to ventilated alveoli (V/Q mismatch)

PE Assessment:

(see graphic)

PE Diagnostic:

– CT angiogram /w contrast
– D-dimer (but this is not first line diagnostic because it is not as accurate)

PE Treatment:

– ABC; O2
– Patient Positioning – Semi Fowler’s
– Blood thinners and anticoags
– Surgical: Embolectomy, vena cava umbrella (prevention)
– Thrombolytics

Pulmonary Embolism

Hemodynamics Definition:

– the study of blood moving through the circulatory system

Hemodynamics Important Aspects:

– preload
– contractility
– afterload

Preload:

– Volume of blood in ventricles at end of diastole

Contractility:

– Ability of the heart to contract

Afterload:

– The force or resistance against which the heart pumps

True/False: To increase preload and cardiac output, fluid bolus of roughly 1L may be ordered by the provider

True, set the pump to 999ml/hr rate

What does dobutamine treat?

– Heart failure; stimulates heart muscle and improves blood flow by helping the heart pump better.

What does desmopressin do?

– decreases urine output in pts with DI

What does epinephrine do?

– Increase heart rate

What does norepinephrine do?

– Influences peripheral vasoconstriction and blood pressure

Cardiac Output (CO):

– Volume of blood in liters pumped by the heart in 1 minute (L/min). Cardiac index (CI) is the measurement of CO adjusted for body surface area (BSA). It is a more precise measurement of the efficiency of the heart’s pumping action.
– HR x SV…4-6 L/min at rest

What is ejection fraction?

– Stroke volume/end diastolic volume
– 65-70% is ideal range, but not less; eg. an EF of 20% is a major concern!!

What are the indications for an echocardiogram?

– Valvular disease or dysfunction:

– Myocardial disease
– Abnormalities of cardiac blood flow
– Cardiac anomalies in the infant
– Abnormal heart sounds

What is MAP?

– Mean arterial pressure; what perfuses the body…the body likes a MAP of at least 65-70; below 65 is a major concern!

What organ begins to fail first with a low MAP?

– The kidneys

How To Calculate MAP:

– To calculate a mean arterial pressure, double the diastolic blood pressure and add the sum to the systolic blood pressure. Then divide by 3.

What is CVP?

– Central venous pressure which measures the amount of blood going into the right side of the heart; 2-6 mmHG

What does a CVP of 0 mean?

– Patient has fluid deficit = dehydrated; notify provider for order…fluid bolus is a possible order

What does a CVP of 18 mean?

– Patient has fluid overload; notify provider for order

What is PVR?

– Pulmonary vascular resistanc; is resistance that the right ventricle must overcome to eject a volume of blood, normally one sixth of SVR

What is blood pressure?

– Flow x resistance; force exerted on the liquid in mmHG

What is the Frank-Starling Law?

– the greater the diastolic filling (preload), the greater the quantity of blood pumped
– increased stretch = increased volume

What influences afterload?

– Vasodilation/ vasoconstriction
– Stenotic valves

What is cardiogenic shock?

– Occurs when the heart is damaged and unable to supply sufficient blood to the body

True/False: Heart Failure produces an elevated preload value and decreased contractility

True; the value will be VERY high and contractility is poor

Hemodynamic Monitoring:

– the use of pressure monitoring devices to directly measure cardiovascular function

Invasive Hemodynamic Monitoring:

– Continuous monitoring of the cardiovascular status by intraarterial catheters and IV lines that measure pressure, volume, and temp.

– A balloon catheter (swanz ganz) is placed in the pulmonary artery to obtain pulmonary artery wedge pressure and LA pressure.

– A thermodilution catheter measures cardiac output.

– Central venous pressure line measures pressure in the Vena cava or R atrium.

FlowTrac Arterial Monitoring:

– A device uses arterial pressure waveform analysis to calculate stroke volume and cardiac output

What does an arterial line do?

– gives constant reading of BP /w every heart beat
– can also draw blood on this for diagnostic tests like ABGs

Pressure Bags:

– 300 mmHG pressure ideal

Arterial Line Dampening:

– Occurs d/t air bubbles, kinks, distensible tubing, low flush bag, clots
– Severe hypotension if all else ruled out
– Under estimates SBP, over est DBP

Arterial Pressure Monitoring – Complications:

– Thrombosis – Proper flushing and possible hep or Lov
– Embolism – Proper flushing and possible hep or Lov and s/s
– Blood Loss/Hemorrhage – tubing tight and connected to ensure no blood loss & pressure for at least 5 mins when removing cath
– Infection- Improper septic techniques

Central Venous Pressure (CVP) Monitoring:

-Normal CVP is 2-5mm Hg

-CVP measures the pressure in the right atrium or vena cava

-Provides information regarding intravascular blood volume

–Measures right ventricular preload

CVP Monitoring Complications:

– infection, pneumothorax, thrombosis, air embolism

Pulmonary Artery Pressure Monitoring:

– Pulmonary artery catheter (PAC), also called a Swan-Ganz
– Reflects LEFT ventricular function
– Measure PA systolic, PA diastolic, and PAWP/PAOP
– PAWP (pulmonary artery wedge pressure) is taken every 2 to 4 hours, leave the balloon inflated just long enough to get a reading, not more than a few seconds
– Nursing: maintain sterility, inserted in jugular vein, subclavian vein, or femoral, keep pt in phlebostatic axis position.

Level of Transducer:

– Each cm above phlebostatic point = below 1.86 mmHg (false low)
– Each cm below phlebostatic point = above false high

Shock Syndrome:

– Acute, widespread impaired tissue perfusion
– Imbalance between cellular oxygen supple and cellular oxygen demand/
– Result = multiple organ failure

What is MODS?

– Multiple organ dysfunction syndrome

What are the four stages of shock?

1. Initial
2. Compensatory
3. Progressive
4. Refractory

Initial Stage of Shock:

– first stage when cells are deprived of oxygen, which inhibits their ability to produce energy

Compensatory Stage of Shock:

– decrease in CO
– sympathetic nervous system to release adrenalin to increase CO, BP, ADH (kidney’s hold onto h20)
– vasoconstriction

Progressive Stage of Shock:

– State of shock that begins when the compensatory mechanisms fail to maintain cardiac output. Tissues become hypoxic, cells switch to anaerobic metabolism, lactic acid builds up, and metabolic acidosis develops.
– Decreased BP, narrow pulse pressure, tachypnea, anuria, cold/clammy…irreversible damage begins

Refractory Stage of Shock:

– This stage of shock is irreversible. Severe acidosis and organ failure occur. Cell death and tissue damage occurs from too little O2 reaching the tissues. There is no response to fluids or vasopressors, and multiple organ failure results.
– Unresponsiveness to therapy, dysrhythmias, respiratory + metabolic acidosis, DIC, MODS, and death is final outcome

Hypovolemic Shock:

– Inadequate fluid volume in intravascular space
– Decrease in tissue perfusion
– Most common form
– Causes: Dehydration, burns, hemorrhage, or DI are some examples

Hypovolemic Hemodynamic Assessment:

– HR increase, CO decreased, CI decreased, CVP decreased, PAOP decreased, and SVR increased

Hypovolemic Shock Management:

– Correct cause, correct hypovolemia via NS or LR, PRBCs

Cardiogenic Shock:

– Failure of heart to pump blood efficiently
– LV MI
– Myocarditis
– Myocardial contusion
– Aortic or mitral stenosis

Cardiogenic Shock Hemodynamics Assessment:

– HR increase, sustained hypotension (systolic blood pressure < 90 mm Hg for ≥30 min) and a reduced cardiac index (< 2.2 L/min/m2) in the presence of normal or elevated pulmonary capillary wedge pressure (>15 mm Hg) or right ventricular end-diastolic pressure (RVEDP) (>10 mm Hg)

Cardiogenic Shock Management:

– Treat underlying cause, enhance effectiveness of the pump with inotropic like dopamine, dobutamine (may drop BP), and diuretics

Intraortic Balloon Pump (IABP):

– Rest = inflate; pumps = deflates
– Decreases afterload; temporary treatment for cardiogenic shock
– Patient must be on flat, bed rest

Ventricular Assist Device (VAD):

– A mechanical pump that helps a weakened ventricle to pump blood throughout the body so that the heart does not have to work as hard; temporary method to buy people time while waiting for a heart transplant
– It lasts 5 to 7 years

Obstructive Shock:

– Circulating blood flow is blocked
– Cardiac tamponade, tension pneumothorax, pericarditis, pulmonary embolism, and severe HTN
– Assessment: HR increased, CO dec., CI dec., CVP inc or normal, PAP inc. or normal, and PAOP inc. or normal
– Management: eliminate the blockage

Anaphylactic Shock:

– A severe systemic hypersensitivity reaction characterized by multisystem involvement
– First – pruritus, flushing, and urticaria
– Next – throat fullness, anxiety, chest tightness, SOB, and lightheadedness
– Finally – altered mental status, respiratory distress, and circulatory collapse
– Assessment: HR inc., CO dec., CI dec, CVP dec., PAOP dec.
– Management: ABCs, remove antigen, epinephrine, diphenhydramine, corticosteroids, and fluid replacement

Categories of Shock:

(see graphic…TPR stands for temperature, pulse, and respirations)

Three Most Common Anaphylatic Causes:

– Antibiotics, food, and insects

Neurogenic Shock:

– Circulatory failure caused by paralysis of the nerves that control the size of the blood vessels, leading to widespread dilation; seen in patients with spinal cord injuries
– Results = hypotension and bradycardia
– Assessment: HR dec, CO dec., CI dec., CVP dec., and SVP dec.
– Management: ABCs, remember cspine precautions, fluid resuscitation, maintain MAP 85-90mmHG, and treat bradycardia with atropine or pacemaker if appropriate

Spinal Shock:

– Physiologic response that occurs between 30 and 60 minutes after trauma to the spinal cord and can last up to several weeks. spinal shock presents with total flaccid paralysis and loss of all reflexes below the level of injury.

Sepsis:

– toxic inflammatory condition arising from the spread of microbes, especially bacteria or their toxins, from a focus of infection; 28-50% chance of dying…sepsis is NOT GOOD

Sepsis Steps:

1. SIRS
2. Sepsis
3. Severe sepsis – Sepsis + End Organ Damage – Hypotension <90 SBP, and Lactate > 4 mmol
4. Septic shock

(see graphic)

What is SIRS?

– systemic inflammatory response syndrome

Sepsis Six:

– high flow oxygen
– blood cultures
– IV antibiotics
– fluid challenge
– measure lactate
– measure urine output

Severe Sepsis and Septic Shock:

– Microorganisms invade the body, initiating a systemic inflammatory response
– S/S: hyperthermia, hypothermia (late sign), tachycardia, wide pulse pressure, low BP (SBP <90), and mental status change

Sepsis Bundle:

(see graphic)

True/False: MAP of <60 we will start to observe multiple organ failure

True, even anything below 65 we have to be cautious of

Sepsis Hemodynamic Assessment:

– HR inc.
– CO/CI inc. (early) / dec. (late)
– CVP dec. (early) / variable (late)
– SVR dec.

Sepsis Management:

– Recognize early!!!
– Treat promptly via Sepsis Bundle
– Fluid Replacement
– Pharmacologic / Eradicate sources of infection / Vasopressors
– Provide oxygenation and ventilation

Prevention of Sepsis:

– Prevent nosocomial infections: ventilator associated pneumonia, catheter-related infections, surgical site infections, and UTI infections
– These cause pain and discomfort, increases mortality, and increase hospital costs

Acute Respiratory Distress Syndrome (ARDS):

– noncardiogenic pulmonary edema
– diagnostic: hypoxia, bilateral infiltrates
– acute lung injury scoring
– complication of other disease process
– direct or indirect pulmonary injury

ARDS Causes:

– chest trauma
– aspiration
– inhalation injury
– near drowning
– fat emboli
– sepsis
– drug overdose
– renal failure
– COPD
– Guillen-Barre syndrome
– Myasthenia Gravis
– Pancreatitis
– Massive blood transfusion

ARDS:

(see graphic)

What ABG abnormality would you see with ARDS?

– Respiratory alkalosis due to hyperventilation

True/False: Pts. who survive ARDS will have some lasting lung compliance issues for up to one year and its lasting affects might be for life

True, the damage to the lungs may be permanent

ARDS S/S:

– tachypnea
– fine crackles
– restlessness
– agitation
– confusion
– tachycardia
– cough
– retraction
– initially respiratory alkalosis
-hypoxia
– ABGS = decreased PO2 and increased Dyspnea

Phases of ARDS:

1. Injury/exudative phase
2. Reparative/proliferative phase
3. Fibrotic phase

ARDS Interventions:

– Mechanical Ventilation – Oxygenate!
– High PEEP levels
– Sedation and paralytics
– Prone positions ARDS protocol – conservative fluid administration except in cases of shock
– Pharmacology – lasix /w albumin, corticosteroids (mixed findings), antibiotics for prevention of VAP, nutritional supplement enteric feedings; recovery may be long and pt. plus family will need psychosocial support

ARDS Interventions:

– Ventilator settings as appropriate
– Suctioning, oral care
– Monitor ABGs, pulse ox
– Monitor ECG, VS
– Positioning Q2Hs
– Coughing and deep breathing
– Prone positioning IF pts. with refractory hypoxemia that do not respond to other strategies to increase PaO2…optimal treatment time is within 24 hours and only in severe cases
– Mortality Rate: 40-100% if combined with two or more other failing organs

ARDS – Prevention:

– Ventilator Bundles, Oral Care…PEEP early, pump cardiovascular treatments, and fluid management
– Paralysis…decreased oxygen demand, must be combined with sedation
– Positioning…labor intensive, improved oxygenation by perfusion of alveoli in dependent positions, and prone positioning, but not used much due to danger…but improvement in prognosis if needed

Train of Four:

– series of four twitches at 2 hz, every half second for 2 sec.
– reflects blockade of 70-100%, useful during onset, maintenance, emergence; determined by comparing T1-T4
– assesses paralytics effectiveness

ARDS Complications:

– Renal failure
– Multiple Organ Dysfunction Syndrome
– Disseminated Intravascular Coagulation (DIC) – clotting + hemorrhaging
– Long-term pulmonary effects associated with high oxygen and other therapies

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