Review for 1166
midterm exam
revised Oct 2010
By
Elizabeth Kelley Buzbee AAS, RRT-NPS, RCP
Question
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You are reading the chart and you need to find
the patient’s current Vital Signs prior to giving
inhaled Beta II bronchodilator.
Where would you look?
answer
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I would first go to the NURSE’S GRAPHIC
SHEET where she charts her scheduled VS.
I would also check the respiratory therapist’s
charting for the last VS with the last treatment
I will also do my own VS prior to starting a
medication because I know that VS change from
minute to minute
Question
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Where in the patient’s chart would you go to
find out what diseases the doctor wants to test
the patient for?
answer
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I would go to the DOCTOR’S PROGRESS
NOTES where the doctor’s SOAP charting will
be found with his PLAN.
I could also look in the PHYSICIANS
ORDERS to see what kind of lab work the
doctor has already ordered.
Question
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Where in the chart would you go to find out
what the doctor wants you to do for this patient
right now?
answer
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I would go to the PHYSICIAN’S ORDERS to
find the current orders I need to do my patient
care.
Question
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Your patient has a HR that is 138 bpm, his
blood pressure is 118/75 mmHg and his RR is
18 bpm.
Are the VS normal?
answer
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a HR that is 138 bpm is elevated
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his blood pressure at 118/75 mmHg is WNL
his RR at 18 bpm is WNL.
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question
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If the doctor has ordered a ultrasonic mist Q 4
hours by aerosol mask with air and you gave the
last one at 2 PM, when is the next one due?
answer
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We would give the next Ultrasonic at 6 PM
question
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If the doctor orders an MID with Atrovent
[ipratropium bromide] TID, how often would
you do this in a 24 hour period
answer
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TID is 3 x a day; Generally we will only do this
while the patient is awake so breakfast, lunch
and dinner time are reasonable
question
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Your patient is getting a SVN with 2.5 mg of
Albuterol in 2. 5 ml of normal saline.
What would be an indication for this
medication?
answer
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It is given to treat or prevent bronchospasm associated
with asthma or COPD
The normal saline will act as a wetting agent to help
loosen secretions; normal saline also dilutes the
Albuterol so that the drug will last 10-12 minutes
Normal saline is less irritating to the airways than sterile
water
question
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Your patient is a 2 year old toddler whose Sp02
is 88% on Room air. He has retractions, nasal
flaring and is breathing rapidly.
You would recommend?
answer
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Supplementary 02 for a child this age would be best
accomplished by placing the child inside a mist tent
[mist tent/croup tent/02 tent are all different names for
the same device.]
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nasal cannula for this-sized child are available
Question
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If you want to find out the patient’s diagnosis,
you could get this information out the chart at
what point?
answer
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I would check the DOCTOR’S PROGRESS NOTES
where the doctor will place his educated guess into the
A [appearance] portion of the SOAP
I would check the PHYSICIANS’ ORDERS for orders
that hint at the diagnosis—for instance: if the
PHYSICIANS’ ORDERS include glucose
measurements after meals and insulin shots obviously,
this patient has diabetes.
if the patient has bronchodilators ordered there is some
problem with the lower airways that results in
bronchospasm
question
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Your PHYCICIAN’s ORDERS include the
phrase “check pulse ox and keep Sp02 above 93%.”
On room air [Fi02 21] your patient’s Sp02 is
96% with a HR 88 bpm and a RR of 12 bpm.
This patient’s major concern is making the TV
work correctly and making sure his lunch comes
on time.
What will you do?
answer
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I would record the Sp02, Fi02 and the HR and
RR in my Respiratory Care charting and not
start 02.
Because there was no frequency on the pulse
oximeter order, I would not repeat the Sp02
unless the patients VS were to worsen-- in which
case I want to make sure the Sp02 is above 93%
because I do have an order for that.
question
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If your patient has increased wheezing and
rhonchi, what would this do to his WOB?
answer
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His WOB would increase as his driving pressure
increases; this could be seen as retractions, and
nasal flaring and increased work of the muscles
of both the abdomen and the chest wall. He
would most likely have increased RR and
increased HR
question
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Your patient who has diminished BBS in the
basal areas of the lung and who has diffuse
crackles. What is the effect of this on this patient
WOB?
answer
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The diminished basal breath sounds imply that
the basal alveoli are collapsed [atelectasis] & this
will require increased driving pressure to reinflate these stiffened lung units.
The crackles also imply that there is atelectasis.
This patient’s WOB is increased due to
decreased lung compliance.
question
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Your patient has intercostal retractions and is
breathing fast.
Might she be in respiratory distress?
What might you recommend?
answer
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Yes, she is showing s/s of increased WOB
I would measure her RR, HR and get a Sp02
I would listen to her BBS
Because the AARC Clinical Practice Guidelines
state that I can start 02 for s/s of increased
WOB, I could safely recommend 1-2 lpm nasal
cannula--until I know more.
question
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To assess a patient for a need for SVN with
Albuterol, you would recommend what?
answer
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I would listen to BBS for wheezing or prolonged exhalation
I would check the patient’s history for asthma, COPD or other
disease associated with bronchospasm
I would measure the HR and RR for s/s of increased WOB
I would look at the patient for visible s/s of increased WOB
I would look at the chest for increased AP diameter or observe
the patient’s assumption of the tripod position needed to use
accessory muscles of inspiration
I would percuss the chest for hyper-resonance associated with
air-trapping
I would palpate the belly for tensing of the abdominal muscles
during a forced exhalation with accessory muscles
question
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If your patient has BBS with prolonged
exhalation in the RML and rhonchi over the
RUL what would you recommend?
answer
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I would give Albuterol by SVN to treat the
bronchospasm that is manifested by prolonged
exhalation
The normal saline in the SVN would help
loosen the secretions associated with the
rhonchi
question
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Your patient just pulled an endotracheal tube
out of his throat. Immediately after this, his RR
rises to 32 bpm from 12 bpm, his HR is 110
bpm from 77 and you see that he has
supraclavicular retractions.
When you listen to his breath sounds you hear a
sound associated with upper airway obstruction.
What is this sound?
answer
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Stridor is a sound associated with laryngeal
swelling.
We would also hear this with a child who is
suffering from croup
The cough would be ‘barky’
question
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You started a 45% entrainment mask on a
patient and after 15- 20 minutes you note that
the RR is still 26 bpm and that the Sp02 is still
88%.
You have checked the function of the device.
What do you recommend right now?
answer
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Fi02 45% is not enough; raise it to 50% and
reassess the VS and the Sp02
Suggest an ABG if this change doesn’t increase
the Sp02 to above 90%
Listen to BBS for other problems that need to
be dealt with such as bronchospasm
question
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Your patient is on an bland aerosol mask at
60%. Her RR is 12 bpm and her HR is 88 bpm,
Her Sp02 is 100%.
What do you recommend at this time?
answer
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Because Fi02 is at toxic levels, we need to get
the Fi02 down.
I suggest we decrease the Fi02 from 60% to
50% and recheck the Sp02 & VS
Keep decreasing the Fi02 every 30 minutes as
long as the Sp02 is above 95% and as long as the
patient shows no s/s of increased WOB or
hypoxemia
question
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Your patient is breathing shallowly, and is complaining
of pain during inspiration over the lower right chest
wall.
When you attempt to percuss the patient, he recoils and
c/o pain and tenderness over the lower right chest wall
On auscultation, you hear a rubbing on inspiration.
The nurse recommends you give the SVN with 2.5 mg
Albuterol about 30 minutes early
You reply?
answer
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No, I would not give the SVN early, because
this breath sound is associated with a pleuritic
problems such as effusion or pleurisy-- not
bronchospasm.
We need to notify the doctor of this change
question
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Your patient’s skin is pale, cool and damp. His
capillary refill is 3 seconds and his pulse rate is
rapid and irregular.
The EMS wants to start him on Incentive
spirometry
You recommend?
answer
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We need to get a systemic blood pressure by
cuff because this is a cardiovascular issue & we
need to call the doctor
We need to assess the patient’s LOC
We need to start this patient on 02 for possible
increased work of the heart
We need to watch this patient carefully for
possible s/s of a need for CPR
question
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Your patient has a disease that places him in
RESPIRATORY ISOLATION.
How will you prepare to go into the room
answer
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Wash hands & place gloves [we do this with
everyone]
Place mask on to protect myself
Keep my patient inside the room with the door
shut to protect other folks from the infection
If a ‘laminar flow’ room is available place,
patient inside one.
question
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Your patient has a Sp02 that is only 90% on 8
lpm nasal cannula and the doctor wants to keep
his Sp02 above 93%.
What do you recommend?
answer
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We need to raise the flow rate from 8 lpm to 9 lpm to
get the Sp02 up…..but we cannot go that high on a
nasal cannula.
At this point, we might switch to a simple mask at 9
lpm…but that can only get to Fi02 50% which isn’t
much higher than a 8 lpm N/C which can only get to
45%
We might recommend an entrainment mask at 50%
because the N/C & a simple mask are both low flow
systems which will deliver less 02 as the patient’s
minute ventilation rises
We need to follow up with repeat Sp02, VS and
consider calling the doctor for an ABG if this change
doesn’t fix the Sp02
question
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Dullness to percussion and crackles are
associated with what disorders?
answer
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Alveolar consolidation is associated with
dullness to percussion
Atelectasis is associated with crackles
This could be due to some alveolar involvement
such as pneumonia, pneumonitis or congestive
heart failure
Question
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There is hyper-resonance to percussion and you
see a patient with an increased AP diameter.
What disorders are associated with these?
answer
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these s/s are associated with air-trapping with is
associated with airway obstructions from such
diseases such as in asthma, COPD.
If you listen to the chest you most likely will
hear expiratory wheezes, some course crackles
from fluid in the airways and maybe distant
breath sounds. You may hear prolonged
exhalation time
question
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Your patient has a Pa02 of 45 mmHg on an
entrainment mask at 35%.
To correct his hypoxemia [get the Pa02 to 80
mmHg] what Fi02 should you select?
answer
Pa02 actual : Fi02 actual as Pa02 you want: Fi02 you need
45 mmHg : .35 as 80 mmHg: x
45 X = .35 (80)
45 X = 28
= 62% Fi02 we need
This patient needs a partial Non-rebreather mask
to get the Pa02 back to normal
question
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Your patient has the following:
HR is 88 BPM
RR is 18 BPM
Sp02 is 95%
Patient is alert and resting quietly
There are no retractions, no labored breathing
What could you say about this patient?
answer
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Pt has normal VS and normal Sp02
There are no s/s of respiratory distress nor of
increased WOB
question
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Your patient has been placed on 60%
entrainment device on his face tent. If the set
flow rate is 8 LPM, what is the total flow rate?
answer
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At 60% and 8 LPM
Based on the magic box, there is 1 LPM of air
entrained for each 1 LPM of 02
8 LPM + (8 x 1) = 16 LPM
Question
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In the situation above in which the patient has a
total flow of 16 LPM, could we call the
entrainment device a high flow system?
answer
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Not really, the flow rate needs to be 2-3 x the
VE to be a true high flow system.
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We could increase the 02 flow to 15 which
would result in a total flow of 30 LPM which is
better
question
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If you hear bronchial breath sounds over the
larger airways this would be:
answer
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This is normal over the larger airway.
If this same sound was heard over the periphery
of the lung we would be concerned about
atelectasis or pneumonia in which the lung has
become more dense
question
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If your patient has rhonchial fremitus on
palpation, and you hear coarse inspiratory &
expiratory crackles that clear after a cough, your
patient has what problem ?
answer
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Coarse crackles and rhonchial fremitus are both
associated with fluid in the airways which would
change with coughing effectively.
This could be associated with bronchitis
question
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Your order states that you must keep your
patient Sp02 above 92%.
Your patient has been gradually increased from
1 LPM nasal cannula to 5 LPM nasal cannula
over a couple hours, the Sp02 is finally above
92%, and the RR has returned to normal with a
normal HR.
What else can you do for your patient to make
him more comfortable?
answer
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Add an cool bubble humidifier to the nasal
cannula
Continue to monitor the VS and Sp02
Question
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Your patient is wearing a Non-rebreather mask
in the recovery room. He is breathing slowly and
shallowly.
For what one particular hazard of 02 might we
be worried about in this case?
answer
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absorption atelectasis is a particular hazard
of patients who are in post op.
Post op patients are already at high risk of postop atelectasis
As the 02 molecules replace the N2 molecules
they are quickly diffuse into the capillaries and
the lung collapses
question
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Your patient has been on 70% 02 for several
days. What single particular hazard of 02 is he at
risk for?
answer
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He is at increased risk of 02 toxicity in which
increased 02 radicals will damage the lung tissue
question
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Your patient has chronic hypercapnia associated
with morbid obesity. His normal Pa02 ranges
between 55- 65 mmHg.
If he is placed on a higher level of Fi02 than he
needs, what particular hazard of 02 would he be
at risk for?
answer
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02 triggering a lost of his hypoxic drive
The Pa02 rises to ‘normal’ his brain stops asking
for breaths
Because the PaC02 started off abnormally high,
and because his body has adjusted to that his
PaC02 starts to rise to the point that it becomes
a sedative [PaC02 above 70 mmHg]
Question
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When performing percussion for diaphragmatic
excursion , we would percuss until the resonance
becomes dull.
This means:
answer
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If you are percussing below the rib cage, you are
percussing abdominal structures; this is the end
of the diaphragm. The diaphargm can be found
between the 9th and the 12th ribs depending on
how deep the breath is.
If you are still above the diaphragm, this change
to dullness would imply that there is
consolidation, atelectasis or pleural effusion
present over the area