SESSION 6
CHECK FOR UNDERSTANDING (60 minutes)
You will answer and rationalize this by yourself. This will be recorded as your quiz. One (1) point will be
given to correct answer and another one (1) point for the correct ratio. Superimpositions or erasures in
you answer/ratio is not allowed. You are given 60 minutes for this activity:
Case Study: Read and examine the case thoroughly.
Patient Profile: T.S. is a 46-year-old female patient who was diagnosed with idiopathic pulmonary
arterial hypertension at the age of 42. At that time, she presented to her primary care health care
provider with a history of increasing fatigue and recent onset of swelling in her feet and ankles. A chest
x-ray revealed severe cardiomegaly with pulmonary congestion. She underwent a right-sided cardiac
catheterization, which showed very high pulmonary artery pressures. Since then, she has been treated
with several drugs but her pulmonary hypertension has never been controlled and her peripheral edema
has progressively worsened.
Subjective Data
Short of breath at rest and exercise intolerant to the extent that she had to quit her job
Recently divorced from her husband
Has two children: a girl, 10 years old, and a boy, 4 years old
Objective Data
3+ pitting edema from her feet to her knees
RR: 28 at rest
HR: 92 bpm and bounding
Discussion Questions
1. What drugs might T.S. have been given to treat her pulmonary hypertension?
Answer: Low-flow oxygen; calcium channel blocking agents (nifedipine [Adalat], diltiazem [Cardizem]);
phosphodiesterase (type 5) enzyme inhibitors (sildenafil [Revatio]); parenteral vasodilators
(epoprostenol [Flolan], adenosine [Adenocard]); inhaled vasodilators (iloprost [Ventavis], treprostinil
[Tyvaso]); endothelin receptor antagonists (bosentan [Tracleer], ambrisentan [Letairis]); diuretics; and
anticoagulants.
2. Is T.S. a candidate for heart-lung or lung transplantation? Why or why not?
Answer: Yes, because her medical treatment has failed, she has worsening right-sided heart failure, and
she potentially can be treated with either a lung or a heart-lung transplant. She meets additional criteria
of being less than 60 years old and a nonsmoker.
3. What transplant procedure would be considered for T.S.? What is the rationale?
Answer: A heart-lung transplant is indicated for T.S. because she has heart damage from the pulmonary
hypertension, although there is evidence that even a single-lung transplantation can markedly correct
pulmonary hypertension and the resultant cor pulmonale.
4. Priority Decision: What priority preoperative teaching is necessary for T.S. to prepare for a
transplant procedure?
Answer: T.S. needs preoperative teaching to help her to cope with the postoperative regimen, which
includes the following:
• Strict adherence to immunosuppressive drugs
• Continuous monitoring and reporting of manifestations of infection
• Self-care activities and accurately identifying when to call the transplant team
• Rehabilitation program
• Financial resources for the procedure, drugs, and follow-up care
• Social and emotional support system because she is a single mother
5. Priority Decision: Based on the assessment data presented, what are the priority nursing
interventions?
Answer: Vital sign and cardiac monitoring, oxygen administration, positioning T.S. in high-Fowler
position, sequential compression stockings, medication administration, and consultation with a chaplain,
social worker, or psychologist for counseling related to recent divorce and care of children while in the
hospital and postoperatively.
Multiple Choice
Situation: the following questions pertains to the clinical decision-making skills and knowledge of a
registered nurse caring for various patients with Disorders associated to Lung Inflation and Obstructive
Airway Conditions.
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
ANSWER: C
RATIO: 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.
ANSWER: A
RATIO: 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 non-rebreather 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).
ANSWER: B
RATIO: 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.
Answer: A The patient is somnolent.
ANSWER: A
RATIO: 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.
ANSWER: B
RATIO: 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.
ANSWER: C
RATIO: 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.
ANSWER: C
RATIO: 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.
ANSWER: A
RATIO: 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.
ANSWER: C
RATIO: 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 client's 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.
ANSWER: C
RATIO: 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.
