(Osborn) Chapter 36: Learning Outcomes (Number and Title)

[Osborn] chapter 36
Learning Outcomes [Number and Title]

Learning Outcome 1
Describe the etiology, incidence, and types of acute respiratory
failure as seen by nurses in acute care settings.
Learning Outcome 2
Define pulmonary edema and state three of the common
etiologies of pulmonary edema that are seen in practice.
Learning Outcome 3
Differentiate between noncardiogenic pulmonary edema and
cardiogenic pulmonary edema, as it relates to patient
symptomology.
Learning Outcome 4
Distinguish between acute respiratory distress syndrome
(ARDS) and acute lung injury (ALI) in patients presenting in
an acute care setting.
Learning Outcome 5
Identify the common ventilator modes and important nursing
implications for each mode.
Learning Outcome 6
Define PEEP and state two complications of this therapy.
Learning Outcome 7
List the equipment needed for intubation, and explain how the
equipment is used with a patient.
Learning Outcome 8
Review the procedure for suctioning and state two important
nursing implications related to conducting this procedure.
Learning Outcome 9
State two indications for insertion of a chest tube in a patient in
an acute care setting.
Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for
Practice Copyright 2010 by Pearson Education, Inc.
1. The client presents with PaO2 of 54 mmHg and an arterial oxygen saturation of 80%.
The nurse recognizes that which of the following is the most likely cause for this type of
acute respiratory failure?
1.
2.
3.
4.
Pneumothorax
Oversedation
Cervical spinal cord injury
Obesity
Correct Answer: Pneumothorax

Rationale: A PaO2 of 54 mmHg and an arterial oxygen saturation of 80% are indicative of
hypoxemic respiratory failure and can be caused by conditions that would lower the
oxygen content of the client. In this instance, a pneumothorax would likely be the cause.
Oversedation and obesity are likely causes of hypercapnia respiratory failure. Cervical
spinal cord injury would result in the central nervous system as a cause.
Cognitive Level: Application
Nursing Process: Planning
Client Need: Physiological Integrity
LO: 1
2. An obese postoperative client without known respiratory or central nervous system

disease is unable to be extubated in the postanesthesia recovery unit due to abnormal
ABG results. The client does not respond to the nurses commands and has a respiratory
rate of 10. What ABG results might the nurse expect?
1.
2.
3.
4.
pH 7.28; PaO2 of 80 mmHg; paCO2 55 mmHg; HCO3 22 mmHg; SaO2 92%

Correct Answer: pH 7.28; PaO2 of 80 mmHg; paCO2 55 mmHg; HCO3 22 mmHg; SaO2
92%
Rationale: The nurse would expect the oversedated, nonresponsive client to potentially
have hypercapnia resulting from the residual of intraoperative medications and the
inability to rid him- or herself of CO2. The other ABG results would indicate hypoxemic
respiratory failure, an unlikely finding since the client had no prior respiratory history.
Cognitive Level: Analysis
Nursing Process: Assessment
LO: 1
3. A client presents to the emergency department complaining of sudden onset of

increased weakness and tingling of the lower extremities that has progressed to the upper
arms. The client is diagnosed with Guillain-Barre. The clients respiratory rate is 8; blood
pressure is 86/48. The client is being prepared for intubation. What would the nurse
anticipate the blood gases to be?
High PaCO2
1.
Low PaCO2
2.
High HCO3
3.
High pH
4.
Correct Answer: High PaCO2
Rationale: The nurse would anticipate the client with progressing Guillain-Barre to have
hypoventilation, which results in high PaCO2 levels. The respiratory rate of 8 also would
indicate hypoventilation. The nurse would also anticipate the pH to be low (acidic), not
high, since a high level of CO2 will increase the acidity of the blood. A low PaCO2 results
with tachypnea, which this client does not have. A low PaCO2, high HCO3, and high pH
are all alkolotic states.
LO: 1
4. A client presents to the emergency department (ED) with symptoms of pulmonary

edema. It is important for the ED nurse to determine which of the following as part of the
clients history?
1.
2.
3.
4.
Cardiac and pulmonary history

Renal and cardiac history
Pulmonary and renal history
Recent drug use and past vaccination record
Correct Answer: Cardiac and pulmonary history

Rationale: Attempting to determine a cause for pulmonary edema will assist the health
care team in providing appropriate care. Cardiogenic and noncardiogenic pulmonary
edemas have different approaches to treatment. The renal history will be addressed, but is
not a priority assessment when the client first comes to the ED. Recent drug use and past
vaccination record will be details the nurse will ask during the admission process, but are
not important data initially in the ED when presenting with pulmonary edema.
LO: 2
5. A 70-year-old client presents to the clinic with acute onset of dyspnea and increased
respiratory secretions. The health care provider diagnoses the client with pulmonary
edema. The family asks the nurse what that means. The nurse correctly states that
pulmonary edema:
1. Is too much fluid in the lungs.
2. Is a narrowing of the coronary vessels that causes the heart to stop working
correctly.
3. Rarely affects individuals older than 60.
4. Is caused by a persons excessive working when younger.
Correct Answer: Is too much fluid in the lungs.
Rationale: Pulmonary edema is the accumulation of excess fluid in the lungs caused by
cardiac and noncardiac factors. Heart failure is often seen in individuals older than 65 and
is a common cause of pulmonary edema in elders. There is no evidence that pulmonary
edema is related to an individuals work history when younger. A narrowing of the
coronary vessels (i.e., a potential heart attack) could contribute to heart failure, which
could cause pulmonary edema, but there is no evidence from the question that this is the
cause.
Nursing Process: Implementation
LO: 2
6. A client was admitted 3 days ago with a myocardial infarction and has developed
pulmonary edema. The family is asking the nurse about the cause of pulmonary edema.
The nurse shares with the family which of the following best explanations?
1. The cardiac muscle has been injured and is not able to efficiently pump the blood
through the clients system, resulting in an increased pressure in the pulmonary
system.
2. The pulmonary system was injured first due to hypoxia, which caused the heart
attack.
3. The cardiac muscle is working too hard to push fluids through the pulmonary
system and there is fluid excess as a result.
4. The pulmonary system has an excessive amount of fluid that has been building
over the last several days and now the heart is no longer able to keep up with the
demands.
Correct Answer: The cardiac muscle has been injured and is not able to efficiently pump
the blood through the clients system, resulting in an increased pressure in the pulmonary
system.
Rationale: During an MI, the cardiac muscle is injured and is not able to efficiently pump
blood through the system. This decrease in pumping action results in an increased
pulmonary pressure, which causes fluid to fill the interstitial spaces. The other
explanations are not correct because the pulmonary system did not cause the MI, the MI
causes pulmonary edema; it is not that the cardiac muscle is working too hard, but instead
it is not working as well as it used to; and the pulmonary fluid overload is a direct result
of the MI, not building up over several days.
LO: 2
7. The nurse is giving a report to the oncoming ICU shift for the most recent admission.
The nurse indicates the client is hypotensive, has an S3 heart sound, has crackles, has pink
frothy sputum, and the skin is diaphoretic and cool. The oncoming shift recognizes the
differences between cardiogenic pulmonary edema (CPE) and noncardiogenic pulmonary
edema (NCPE) as:
1. CPE clients will be hypotensive, have an S3 heart sound, and be cool and
diaphoretic.
2. NCPE clients will be hypotensive, have an S3 heart sound, and have a cough.
3. CPE clients will be hypotensive, have an S3 heart sound, and have bounding
pulses.
4. NCPE clients will be hypertensive, have bounding pulses, and have jugular
vein distension.
Correct Answer: CPE clients will be hypotensive, have an S3 heart sound, and be cool and
diaphoretic.
Rationale: This client has CPE, as evidenced by the symptoms of hypotension, an S3 heart
sound, and being cool and diaphoretic. Crackles and pink frothy sputum are found in both
CPE and NCPE. NCPE clients will have hypertension, bounding pulses, and will be
warm and dry.
LO: 3
8. An ICU nurse has been taking care of a septic client. The client suddenly develops
dyspnea, crackles, hypertension, bounding pulses, agitation, and confusion. The nurse
recognizes these are symptoms of:
1.
2.
3.
4.
Noncardiogenic pulmonary edema.

Right-sided heart failure.
Left-sided heart failure.
Constrictive pericarditis.
Correct Answer: Noncardiogenic pulmonary edema.

Rationale: The septic client who suddenly develops dyspnea, crackles, hypertension,
bounding pulses, agitation, and confusion most likely has developed noncardiogenic
pulmonary edema. Agitation and confusion are often among the first signs of developing
hypoxemia, which would be common to both cardiogenic and noncardiogenic pulmonary
edema. Hypertension and bounding pulses are more common with noncardiogenic
pulmonary edema. Right-sided heart failure, left-sided heart failure, and constrictive
pericarditis are considered cardiogenic causes for pulmonary edema.
LO: 3
9. A student is accompanying the nurse today. A newly admitted ICU client with a
diagnosis of pulmonary edema has an elevated JVD and an S3. Based upon these
assessment findings, the nurse indicates to the student that this is which type of
pulmonary edema?
1. Cardiogenic
2. Neurogenic
3. High altitude
4. Excessive IV fluid administration
Correct Answer: Cardiogenic
Rationale: The nurse knows that cardiogenic pulmonary edema clients will have elevated
JVD and an S3 extra heart sound. Cardiogenic-related pulmonary edema clients may also
have hypotension with tachycardia instead of tachycardia with hypertension found with
noncardiogenic causes. Neurogenic, high altitude, and excessive IV fluid administration
are all types of noncardiogenic pulmonary edema.
LO: 3
10. An ICU client who was in a motor vehicle accident 1 day ago is developing a
worsening respiratory status. The nurse is aware that the clients chest has bruising on it
from hitting the steering wheel, and the health care provider has diagnosed the client with
lung contusions. As the client develops increased respiratory distress, the nurse
recognizes that the only difference between acute lung injury (ALI) and acute respiratory
distress syndrome (ARDS) is:
1.
2.
3.
4.
ARDS and ALI differ only in the amount of hypoxemia.

ARDS clients will have a lower respiratory rate than ALI clients.
ALI clients have fewer injuries than ARDS clients.
ALI clients have more inflammation than ARDS clients.
Correct Answer: ARDS and ALI differ only in the amount of hypoxemia.
Rationale: The difference between ALI and ARDS is based upon the amount of
hypoxemia. ALI is less severe of a disease process. The other answer choices are not
representative of the difference between ARDS and ALI.
Nursing Process: Diagnosis
LO: 4
11. The client has just been diagnosed with acute respiratory distress syndrome (ARDS).
The nurse is aware that both acute lung injury (ALI) and ARDS clients will often require:
Mechanical ventilation.
Frequent suctioning.
Frequent ice chips.
A living will.
Correct Answer: Mechanical ventilation.

Rationale: ALI and ARDS clients will likely require mechanical ventilation to support
their respiratory status. While they may also require frequent suctioning, this is more
client specific. Frequent ice chips and a living will are not necessary for ALI and ARDS
clients.
LO: 4
12. An ICU clients chest x-ray results indicate bilateral patchy infiltrates. The client is
hypoxic. The client is being prepared for intubation. The ABGs indicate alkolosis. What
other assessment findings might the nurse anticipate if the clients condition continues to
worsen?
Hypotension
1.
Hypertension
2.
Decreasing HCO3
3.
Hyperventilation
4.
Correct Answer: Hypotension
Rationale: The worsening client will eventually develop hypotension and acidosis. Thus,
as the client continues to fail, the client will not develop hypertension. The HCO3 may
increase to attempt to compensate for the developing acidosis. Hyperventilation is an
early sign of ARDS and will help create the initial alkolosis.
LO: 4
13. A mechanically ventilated client develops respiratory alkalosis while on the ventilator.
The high-pressure alarm has sounded frequently for this client. The ICU nurse suspects
which of the following?
1.
2.
3.
4.
The client is on assist control mode.

The client is on SIMV mode and the set rate is too low.
The client is on pressure support mode.
The client is on pressure-controlled setting.
Correct Answer: The client is on assist control mode.

Rationale: A frequent problem with assist control mode is stacked breaths, and the client
can develop respiratory alkalosis. SIMV mode with a set rate too high may also cause
respiratory alkalosis, but this is uncommon. This client is most likely not on pressure
support mode or pressure-controlled setting.
Client Need: Safe, Effective Care Environment
LO: 5
14. The ventilated ICU client develops hypotension after the respiratory therapist
implements the most recent health care provider orders. The nurse suspects which
ventilator mode might be the cause?
1.
2.
3.
4.
PEEP
SIMV mode
Assist control mode
Pressure-controlled setting
Correct Answer: PEEP

Rationale: Increasing PEEP levels can cause declining blood pressure. Hypotension is not
commonly caused by the adjustment of other modes on the ventilator.
LO: 5
15. A client is on SIMV with a rate of 24. The nurse may question this order since:
1. The rate could be too high for this mode.
2. The client will be more comfortable with a different mode.
3. The client is not receiving enough sedation.
4. SIMV is always used in combination with PEEP.
Correct Answer: The rate could be too high for this mode.
Rationale: SIMV is usually set so that the client can breathe over the set rate to exercise
the respiratory muscles. A rate of 24 will not allow this and could also establish
autoPEEP. The client will not necessarily be more comfortable with a different mode
SIMV is the most commonly used mode in an ICU setting. Too much sedation is
contraindicated in SIMV, so that the client will initiate breaths on his or her own. PEEP
can be used with any of the modes.
LO: 5
16. The mechanically ventilated client requires increasing PEEP for worsening ARDS.
The order for PEEP is now at 20 cm of H2O. The nurse will need to contact the health
care provider immediately if the client develops which of the following?
1.
2.
3.
4.
Lung sounds greater on one side than the other

Lung sounds with crackles
Diminished peripheral pulses
High-pressure alarm
Correct Answer: Lung sounds greater on one side than the other
Rationale: A potential complication from increasing PEEP is a pneumothorax. The nurse
needs to be alert to diminishing or absent lung sounds on one side of the chest. Crackles
and diminished peripheral pulses would not be related to the pneumothorax. A lowpressure alarm would be more likely to sound if the client developed a pneumothorax.
LO: 6
17. The mechanically ventilated client who suddenly develops cardiac arrhythmias from
increasingly higher PEEP most likely has an underlying issue from which of the
following?
1.
2.
3.
4.
Decreased cardiac output and acidosis

Increased cardiac output and alkalosis
Decreased cardiac output and renal failure
Increased cardiac output and electrolyte disturbance
Correct Answer: Decreased cardiac output and acidosis

Rationale: Increasingly higher PEEP with decreased cardiac output and acidosis may
predispose the client to cardiac arrhythmias. The other answer choices are not the most
likely underlying issues.
LO: 6
18. A client has ventilator settings as follows: SIMV 16, PEEP 20 cm of H2O, FiO2 45%,
tidal volume .450 liters. What concerns will the nurse have for this client?
1.
2.
3.
4.
Barotrauma
Volutrauma
Sinusitis
Oxygen toxicity
Correct Answer: Barotrauma

Rationale: This client will be at risk for barotraumas due to the high PEEP levels. The
tidal volume is within a standard setting. However, if it were high, it could lead to
volutrauma. Sinusitis is a potential complication of ventilated clients, but this client
should not have any higher risk for this. The FiO2 is set at 45%, which is not high. A FiO2
greater than 50% for an extended period of time can lead to oxygen toxicity.
LO: 6
19. The ICU nurse consulted with the clients health care provider and the decision was
made to intubate the client. The nurse anticipates the health care provider will require
which of the following items in order to successfully intubate the client?
1. Nonsterile gloves, stylet, endotracheal tube, lubricant, laryngoscope handle and
blade, resuscitation bag with a swivel adapter, and syringe
2. Gloves, lubricant, laryngoscope handle and blade, resuscitation bag with a swivel
adapter, and ventilator
3. Sterile gloves, endotracheal tube, lubricant, laryngoscope handle and blade,
resuscitation bag with a swivel adapter, and syringe
4. Gloves, stylet, lubricant, laryngoscope handle and blade
Correct Answer: Nonsterile gloves, stylet, endotracheal tube, lubricant, laryngoscope
handle and blade, resuscitation bag with a swivel adapter, and syringe
Rationale: The most inclusive list entails the nonsterile gloves, stylet, endotracheal tube,
lubricant, laryngoscope handle and blade, resuscitation bag with a swivel adapter, and
syringe. The other lists exclude important items. The client can be manually ventilated
until a ventilator arrives. Sterile gloves are not required.
Client Need: Safe, Effective Environment
LO: 7
20. The ICU nurse is contacted by the x-ray department following a postintubation chest
x-ray. The nurse is advised that the endotracheal tube is located in the right bronchus. The
nurse recognizes that the correct intervention for this problem is:
1.
2.
3.
4.
The tube needs to be withdrawn slightly.

The tube needs to be inserted further.
The tube is correctly placed.
The tube is incorrectly attached to the ventilator.
Correct Answer: The tube needs to be withdrawn slightly.

Rationale: The right bronchus is easy to intubate due to the anatomy of the lung. If the
tube is located in the right bronchus, it will need to be withdrawn slightly so that both
lungs can be ventilated.
LO: 7
21. An intubated client has the following assessment data: rhonchi, pulse oximeter 92%,
soft abdomen, heart rate 88, blood pressure 98/54. What is the nurses first priority?
1. Suction the client.
2. Contact the health care provider.
3. Increase the oxygen.
4. Start dopamine.
Correct Answer: Suction the client.
Rationale: The presence of rhonchi suggests the client needs to be suctioned. The other
assessment data are of no consequence; therefore there is no need to contact the health
care provider or increase the oxygen. The relative hypotension can be caused by the client
being ventilated and does not require dopamine for blood pressure support.
LO: 7
22. Which health care provider order should the nurse question?
1.
2.
3.
4.
Endotracheal suctioning every hour

Endotracheal suctioning as needed
Maintain NPO status while client is ventilated
Intake and output every 4 hours
Correct Answer: Endotracheal suctioning every hour

Rationale: Suctioning of a client should always be based upon client need and not
routinely ordered. The other orders would be not be abnormal.
LO: 8
23. The client is on PEEP of 10 cm of H2O. The nurse ensures that which of the following
is utilized for this client?
1.
2.
3.
4.
Closed-system suctioning
Oral care daily
Open-system suctioning
Vital signs every shift
Correct Answer: Closed-system suctioning

Rationale: Closed-system suctioning should be utilized for clients with high PEEP and
those who potentially have an aerosolized infectious disease. Oral care should be frequent
and is related to intubation, not particularly PEEP. With high levels of PEEP, frequent
vital signs and assessments are required to detect any potential complications.
Client Need: Health Promotion and Maintenance
LO: 8
24. A ventilated client has become hypoxic, with a pulse oximeter reading falling from
98% to 88%. The high-pressure alarm is sounding on the ventilator. The nurse has
checked the tubing integrity and found no problems. The nurse has assessed the lung
sounds and the sounds are equal bilaterally, but adventitious sounds are present. What
action will the nurse take next?
1. Suction the client.
2. Contact the health care provider.
3. Turn the client on his side.
4. Silence the alarm.
Correct Answer: Suction the client.
Rationale: When the tubing integrity is intact and the high-pressure alarm is sounding,
along with pulse oximeter readings falling from 98% to 88% and adventitious breath
sounds present, this indicates the client needs to be suctioned. The health care provider
will not need to be contacted unless the nursing actions are unsuccessful at resolving the
hypoxia. Turning the client on his side has no purpose. Silencing the alarm will not
resolve the issue.
LO: 8
25. The family of a mechanically ventilated client receiving a chest tube asks why the
tube is necessary. The nurse responds:
1. The chest tube helps to decompress the lung and prevents further complications.
2. The chest tube helps the client breathe more easily when on a ventilator.
3. The chest tube is an elective procedure that many health care providers like to
perform.
4. The chest tube requires the client to go to surgery for placement.
Correct Answer: The chest tube helps to decompress the lung and prevents further
complications.
Rationale: The chest tube is indicated for a pneumothorax that can be spontaneous or
brought on by increasingly higher PEEP. It will not be an elective procedure and is most
often performed at the bedside. A chest tube does not directly assist a client with
breathing easier on a ventilator, but it will allow the lung to expand more fully, which
helps with the clients overall oxygenation.
LO: 9
26. A client is receiving a tracheostomy. The nurse has which of the following ready in
case of a potential complication?
1.
2.
3.
4.
Chest tube set-up

Surgical team on standby
Sedation
Aerosol treatment
Correct Answer: Chest tube set-up

Rationale: One of the complications of the insertion of a tracheostomy is a
pneumothorax. Therefore, a chest tube set-up should be available during and immediately
after the procedure. A surgical team is not always necessary for placement of a
tracheostomy, but can be performed in the operating room at the discretion of the
surgeon. However, the insertion of a tracheostomy is not considered a complication, and
therefore a surgical team on standby as a potential complication is not required. Sedation
and aerosol treatments are required in case of a potential complication. These are routine
treatments.
Client Need: Safe and Effective Environment
LO: 9
27. It is the beginning of the shift and the nurse has just received reports on four clients.
Which client is it most important for the nurse to visit first?
1. Client with a chest tube complaining of difficulty breathing
2. Client with a tracheostomy who is on oxygen via trach mask
3. Client preparing for discharge following a lengthy hospital stay for ARDS
4. Client complaining of incisional pain
Correct Answer: Client with a chest tube complaining of difficulty breathing.
Rationale: The nurse first will want to check on the client with a chest tube who is
complaining of difficulty breathing, as many potential complications will need to be
evaluated. The client complaining of incisional pain will need to be assessed for pain
medication following the first client. Then the client with a tracheostomy who is having
no problems will need to be assessed, followed by the client preparing for discharge.
LO: 9

(Osborn) Chapter 36: Learning Outcomes (Number and Title)

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[Osborn] chapter 36

Learning Outcomes [Number and Title]

Correct Answer: Pneumothorax

2. An obese postoperative client without known respiratory or central nervous system

pH 7.28; PaO2 of 80 mmHg; paCO2 55 mmHg; HCO3 22 mmHg; SaO2 92%

3. A client presents to the emergency department complaining of sudden onset of

4. A client presents to the emergency department (ED) with symptoms of pulmonary

Cardiac and pulmonary history

Correct Answer: Cardiac and pulmonary history

Noncardiogenic pulmonary edema.

Correct Answer: Noncardiogenic pulmonary edema.

ARDS and ALI differ only in the amount of hypoxemia.

Correct Answer: Mechanical ventilation.

The client is on assist control mode.

Correct Answer: The client is on assist control mode.

Correct Answer: PEEP

Lung sounds greater on one side than the other

Decreased cardiac output and acidosis

Correct Answer: Decreased cardiac output and acidosis

Correct Answer: Barotrauma

The tube needs to be withdrawn slightly.

Correct Answer: The tube needs to be withdrawn slightly.

Endotracheal suctioning every hour

Correct Answer: Endotracheal suctioning every hour

Correct Answer: Closed-system suctioning

Chest tube set-up

Correct Answer: Chest tube set-up

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