Chapter 14: Acute Respiratory Failure My Nursing Test Banks

Chapter 14: Acute Respiratory Failure

Test Bank

MULTIPLE CHOICE

1. The nurse is caring for a patient with acute respiratory failure and identifies Risk for Ineffective Airway Clearance as a nursing diagnosis. A nursing intervention relevant to this diagnosis is:

a.

Elevate head of bed to 30 degrees.

b.

Obtain order for venous thromboembolism prophylaxis.

c.

Provide adequate sedation.

d.

Reposition patient every 2 hours.

ANS: D

Repositioning the patient will facilitate mobilization of secretions. Elevating the head of bed is an intervention to prevent infection. Venous thromboembolism prophylaxis is ordered to prevent complications of immobility. Sedation is an intervention to manage anxiety, and administration of sedatives increases the risk for retained secretions.

DIF: Cognitive Level: Analysis REF: Nursing Care Plan

OBJ: Formulate a plan of care for the patient with acute respiratory failure.

TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity

2. The patient with acute respiratory distress syndrome (ARDS) would exhibit which of the following symptoms?

a.

Decreasing PaO2 levels despite increased FiO2 administration

b.

Elevated alveolar surfactant levels

c.

Increased lung compliance with increased FiO2 administration

d.

Respiratory acidosis associated with hyperventilation

ANS: A

Patients with ARDS often have hypoxemia refractory to treatment. Surfactant levels are often diminished in ARDS. Compliance decreases in ARDS. In early ARDS, hyperventilation may occur along with respiratory alkalosis.

DIF: Cognitive Level: Comprehension REF: p. 410

OBJ: Describe the pathophysiology of ARF.

TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

3. The nurse assesses a patient who is admitted for an overdose of sedatives. The nurse expects to find which acid-base alteration?

a.

Hyperventilation and respiratory acidosis

b.

Hypoventilation and respiratory acidosis

c.

Hypoventilation and respiratory alkalosis

d.

Respiratory acidosis and normal oxygen levels

ANS: B

Hypoventilation is common after overdose and results in impaired elimination of carbon dioxide and respiratory acidosis. The overdose depresses the respiratory drive, which results in hypoventilation, not hyperventilation. Hypoxemia is expected secondary to depressed respirations.

DIF: Cognitive Level: Analysis REF: p. 401

OBJ: Describe the pathophysiology of ARF.

TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

4. Intrapulmonary shunting refers to:

a.

alveoli that are not perfused.

b.

blood that is shunted from the left side of the heart to the right and causes heart failure.

c.

blood that is shunted from the right side of the heart to the left without oxygenation.

d.

shunting of blood supply to only one lung.

ANS: C

Shunting refers to blood that is not oxygenated in the lungs.

DIF: Cognitive Level: Comprehension REF: p. 401

OBJ: Describe the pathophysiology of ARF.

TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

5. When fluid is present in the alveoli:

a.

alveoli collapse and atelectasis occurs.

b.

diffusion of oxygen and carbon dioxide is impaired.

c.

hypoventilation occurs.

d.

the patient is in heart failure.

ANS: B

Fluid prevents the diffusion of gases. It does not cause atelectasis or hypoventilation. Fluid can be present in the alveoli secondary to heart failure; however, there are other causes as well, such as acute respiratory distress syndrome.

DIF: Cognitive Level: Comprehension REF: p. 408

OBJ: Describe the pathophysiology of ARF.

TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

6. In assessing a patient, the nurse understands that an early sign of hypoxemia is:

a.

clubbing of nail beds

b.

cyanosis

c.

hypotension

d.

restlessness

ANS: D

Central nervous system signs, such as restlessness, are early indications of low oxygen levels. Clubbing is a sign of chronic hypoxemia. Cyanosis is a late sign of hypoxemia. Tachycardia and increased blood pressure, not hypotension, may be seen early in hypoxemia.

DIF: Cognitive Level: Comprehension REF: p. 403

OBJ: Describe methods for assessing the patient with ARF.

TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

7. The basic underlying pathophysiology of acute respiratory distress syndrome results from:

a.

a decrease in the number of white blood cells available.

b.

damage to the right mainstem bronchus.

c.

damage to the type II pneumocytes, which produce surfactant.

d.

decreased capillary permeability.

ANS: C

Acute respiratory distress syndrome results in damage to the pneumocytes, increased capillary permeability, and noncardiogenic pulmonary edema.

DIF: Cognitive Level: Comprehension REF: p. 408 | Figure 14-2

OBJ: Describe the pathophysiology of ARF.

TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

8. The nurse is caring for a patient with acute respiratory distress syndrome who is hypoxemic despite mechanical ventilation. The physician orders a nontraditional ventilator mode as part of treatment. Despite sedation and analgesia, the patient remains restless and appears to be in discomfort. The nurse informs the physician of this assessment and anticipates an order for:

a.

continuous lateral rotation therapy.

b.

guided imagery.

c.

neuromuscular blockade.

d.

prone positioning.

ANS: C

Paralysis and additional sedation may be needed if the patient requires nontraditional ventilation. Guided imagery is an excellent non-pharmacological approach to manage anxiety; however, the non-traditional mode of ventilation usually requires that the patient receive neuromuscular blockade. Prone positioning is a treatment for refractory hypoxemia but not indicated until the neuromuscular blockade has been tried.

DIF: Cognitive Level: Analysis REF: p. 412

OBJ: Discuss medical management of the patient with ARF.

TOP: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity

9. A patient presents to the emergency department in acute respiratory failure secondary to community-acquired pneumonia. The patient has a history of chronic obstructive pulmonary disease. The nurse anticipates which treatment to facilitate ventilation?

a.

Emergency tracheostomy and mechanical ventilation

b.

Mechanical ventilation via an endotracheal tube

c.

Noninvasive positive-pressure ventilation (NPPV)

d.

Oxygen at 100% via bag-valve-mask device

ANS: C

Noninvasive measures are often recommended in the initial treatment of the patient with chronic obstructive pulmonary disease to prevent intubation and ventilator dependence. The history of chronic obstructive pulmonary disease increases the risk for ventilator dependence, so noninvasive options are a priority. Bag-valve ventilation with 100% oxygen is not required at this time and could depress the respiratory drive that exists. Emergency tracheostomy is not indicated, as there is an indication of an obstructed airway.

DIF: Cognitive Level: Analysis REF: p. 404

OBJ: Discuss medical management of the patient with ARF.

TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

10. Which of the following acid-base disturbances commonly occurs with the hyperventilation and impaired gas exchange seen in severe exacerbation of asthma?

a.

Metabolic acidosis

b.

Metabolic alkalosis

c.

Respiratory acidosis

d.

Respiratory alkalosis

ANS: C

Although the patient with a severe exacerbation of asthma hyperventilates, gas exchange is impaired, which causes respiratory acidosis.

DIF: Cognitive Level: Comprehension REF: p. 401

OBJ: Describe the pathophysiology of ARF.

TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

11. An acute exacerbation of asthma is treated with which of the following?

a.

Corticosteroids and theophylline by mouth

b.

Inhaled bronchodilators and intravenous corticosteroids

c.

Prone positioning or continuous lateral rotation

d.

Sedation and inhaled bronchodilators

ANS: B

Inhaled bronchodilators and intravenous corticosteroids are standard treatment for the exacerbation of asthma; they promote dilation of the bronchioles and decreased inflammation of the airways. Proning and continuous lateral rotation are therapies to treat hypoxemia secondary to acute respiratory distress syndrome. Sedation is not recommended.

DIF: Cognitive Level: Comprehension REF: p. 404

OBJ: Discuss medical management of the patient with ARF.

TOP: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

12. The nurse is discharging a patient home following treatment for community-acquired pneumonia. As part of the discharge teaching, the nurse instructs:

a.

If you get the pneumococcal vaccine, youll never get pneumonia again.

b.

It is important for you to get an annual influenza shot to reduce your risk of pneumonia.

c.

Stay away from cold, drafty places because that increases your risk of pneumonia when you get home.

d.

Since you have been treated for pneumonia, you now have immunity from getting it in the future.

ANS: B

The influenza vaccine reduces the risk of pneumonia by over a half. The pneumococcal vaccine is important but only protects against pneumococcal infection. Cold, drafty environments will not cause infection. Immunity for pneumonia does not occur as a result of getting it.

DIF: Cognitive Level: Analysis REF: p. 419

OBJ: Formulate a plan of care for the patient with ARF.

TOP: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

13. The nurse is discharging a patient with asthma. As part of the discharge instruction, the nurse instructs the patient to prevent exacerbation by:

a.

obtaining an appointment for follow-up pulmonary function studies 1 week after discharge.

b.

limiting activity until patient is able to climb two flights of stairs.

c.

taking all asthma medications as prescribed.

d.

taking medications on a prn basis according to symptoms.

ANS: C

Exacerbation of asthma is often related to not adhering to the therapeutic regimen; patient teaching is essential. Follow-up studies will be determined by the physician. Activity is based on the patients activity tolerance and is not limited. Medications are taken regularly to avoid exacerbation. Only rescue medications are used on a prn basis.

DIF: Cognitive Level: Analysis REF: pp. 416-417

OBJ: Formulate a plan of care for the patient with ARF.

TOP: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

14. The nurse is caring for a postoperative patient with chronic obstructive pulmonary disease (COPD). Which assessment would be a cue to the patient developing postoperative pneumonia?

a.

Bradycardia

b.

Change in sputum characteristics

c.

Hypoventilation and respiratory acidosis

d.

Pursed-lip breathing

ANS: B

Change in the character of sputum may signal the development of a respiratory infection in the patient with COPD. Additional symptoms include anxiety, wheezing, chest tightness, tachypnea, tachycardia, fatigue, malaise, confusion, fever, and sleeping difficulties.

DIF: Cognitive Level: Analysis REF: p. 413

OBJ: Formulate a plan of care for the patient with ARF.

TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

15. The nurse is caring for a patient with a diagnosis of pulmonary embolism. The nurse understands that the most common cause of a pulmonary embolus is:

a.

amniotic fluid embolus.

b.

deep vein thrombosis from lower extremities.

c.

fat embolus from a long bone fracture.

d.

vegetation that dislodges from an infected central venous catheter.

ANS: B

The most common cause of a pulmonary embolus is deep vein thrombosis. The other responses are less common causes.

DIF: Cognitive Level: Comprehension REF: p. 423

OBJ: Describe methods for assessing the patient with ARF.

TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

16. The nurse is concerned that a patient is at increased risk of developing a pulmonary embolus and develops a plan of care for prevention to include which of the following?

a.

Antiseptic oral care

b.

Bed rest with head of bed elevated

c.

Coughing and deep breathing

d.

Mobility

ANS: D

Mobility helps to prevent deep vein thrombosis and pulmonary embolus. Oral care, head of bed elevation, and coughing and deep breathing assist in preventing pneumonia.

DIF: Cognitive Level: Application REF: p. 424 | Box 14-7

OBJ: Formulate a plan of care for the patient with ARF.

TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

17. Which of the following statements is true regarding venous thromboembolism (VTE) and pulmonary embolus (PE)?

a.

PE should be suspected in any patient who has unexplained cardiorespiratory complaints and risk factors for VTE.

b.

Bradycardia and hyperventilation are classic symptoms of PE.

c.

Dyspnea, chest pain, and hemoptysis occur in nearly all patients with PE.

d.

Most critically ill patients are at low risk for VTE and PE and do not require prophylaxis.

ANS: A

PE should be suspected in any patient who has unexplained cardiorespiratory complaints and risk factors for VTE. Dyspnea, hemoptysis, and chest pain have been called the classic signs and symptoms for PE, but the three signs and symptoms actually occur in less than 20% of cases. Bradycardia and hyperventilation are not classic signs of PE. Most critically ill patients are at high risk for VTE and all should receive prophylaxis.

DIF: Cognitive Level: Analysis REF: p. 424

OBJ: Discuss medical management of the patient with ARF.

TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

18. A patient at high risk for pulmonary embolism is receiving Lovenox. The nurse explains to the patient:

a.

Im going to contact the pharmacist to see if you can take this medication by mouth.

b.

This injection is being given to prevent blood clots from forming.

c.

This medication will dissolve any blood clots you might get.

d.

You should not be receiving this medication. I will contact the physician to get it stopped.

ANS: B

Lovenox, or lowmolecular weight heparin, is recommended for patients at high risk for PE. This patient is at high risk and the medication is indicated. It is given subcutaneously, not by mouth. The drug prevents clots from forming but does not dissolve them.

DIF: Cognitive Level: Application REF: p. 424 | Box 14-7

OBJ: Discuss medical management of the patient with ARF.

TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

19. A definitive diagnosis of pulmonary embolism can be made by:

a.

arterial blood gas (ABG) analysis.

b.

chest x-ray examination.

c.

pulmonary angiogram.

d.

ventilation-perfusion scanning.

ANS: C

The angiogram is the only test that can confirm pulmonary embolism. ABG would only indicate hypoxemia and/or acid-base abnormalities. A chest x-ray study is nonconclusive. A ventilation-perfusion scan is nonconclusive.

DIF: Cognitive Level: Comprehension REF: p. 424 | Box 14-7

OBJ: Discuss medical management of the patient with ARF.

TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

20. A strategy for preventing thromboembolism in patients at risk who cannot take anticoagulants is:

a.

administration of two aspirin tablets every 4 hours.

b.

infusion of thrombolytics.

c.

insertion of a vena cava filter.

d.

subcutaneous heparin administration every 12 hours.

ANS: C

A filter may be inserted as a prevention measure in patients who are at high risk for thromboembolism. Aspirin is not a preventive therapy. Thrombolytics are given to treat, not prevent, pulmonary embolism. Heparin is administered as a prophylaxis in acute care settings. Coumadin is given for long-term prevention in patients at high risk for VTE.

DIF: Cognitive Level: Application REF: p. 424 | Box 14-7

OBJ: Discuss medical management of the patient with ARF.

TOP: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

21. Which of the following treatments may be used to dissolve a thrombus that is lodged in the pulmonary artery?

a.

Aspirin

b.

Embolectomy

c.

Heparin

d.

Thrombolytics

ANS: D

Thrombolytics are useful in the management of pulmonary embolus and are given to dissolve the clot. Heparin will prevent further clot formation, but it will not dissolve the clot. Aspirin is not a thrombolytic agent. An embolectomy is a surgical procedure to remove the clot. Heparin will prevent further clot formation, but it will not dissolve the clot.

DIF: Cognitive Level: Comprehension REF: p. 425

OBJ: Discuss medical management of the patient with ARF.

TOP: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

22. The nurse is assessing a patient. Which assessment would cue the nurse to the potential of acute respiratory distress syndrome (ARDS)?

a.

Increased oxygen saturation via pulse oximetry

b.

Increased peak inspiratory pressure on the ventilator

c.

Normal chest radiograph with enlarged cardiac structures

d.

PaO2/FiO2 ratio > 300

ANS: B

Increased peak inspiratory pressures are often early indicators of ARDS. Oxygen saturation decreases in ARDS. Chest x-ray study will show progressive infiltrates. In ARDS, a PaO2/FiO2 ratio less than 200 is a criterion.

DIF: Cognitive Level: Application REF: pp. 408-410 | Table 14-1

OBJ: Describe methods for assessing the patient with ARF.

TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

23. The nurse calculates the PaO2/FiO2 ratio for the following values: PaO2 is 78 mm Hg; FiO2 is 0.6 (60%).

a.

46.8; meets criteria for ARDS

b.

130; meets criteria for ARDS

c.

468; normal lung function

d.

Not enough data to compute the ratio

ANS: B

78/0.60 = 130, which meets the criteria for ARDS.

DIF: Cognitive Level: Analysis REF: pp. 408-410 | Table 14-1

OBJ: Describe methods for assessing the patient with ARF.

TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

24. The nurse is assessing a patient with acute respiratory distress syndrome. An expected assessment is:

a.

cardiac output of 10 L/min and low systemic vascular resistance.

b.

PAOP of 10 mm Hg and PaO2 of 55.

c.

PAOP of 20 mm Hg and cardiac output of 3 L/min.

d.

PAOP of 5 mm Hg and high systemic vascular resistance.

ANS: B

A normal PAOP with hypoxemia is an expected assessment finding in ARDS. Cardiac output of 10 L/min and low systemic vascular resistance are expected findings in sepsis. PAOP of 20 mm Hg and cardiac output of 3 L/min are expected findings in heart failure. PAOP of 5 mm Hg and high systemic vascular resistance are expected findings in hypovolemic shock.

DIF: Cognitive Level: Analysis REF: pp. 408-410 | Table 14-1

OBJ: Describe methods for assessing the patient with ARF.

TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

25. The nurse is caring for a patient who is being turned prone as part of treatment for acute respiratory distress syndrome. The nurse understands that the priority nursing concern for this patient is which of the following?

a.

Management and protection of the airway

b.

Prevention of gastric aspiration

c.

Prevention of skin breakdown and nerve damage

d.

Psychological support to patient and family

ANS: A

All are important, but protection of the airway is the most important intervention if the patient is placed in the prone position.

DIF: Cognitive Level: Comprehension REF: p. 412

OBJ: Describe the pathophysiology of ARF.

TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

26. During rounds, the physician alerts the team that proning is being considered for a patient with acute respiratory distress syndrome. The nurse understands that proning is:

a.

an optional treatment if the PaO2/FiO2 ratio is less 100.

b.

less of a risk for skin breakdown because the patient is face down.

c.

possible with minimal help from co-workers.

d.

used to provide continuous lateral rotational turning.

ANS: A

Proning is considered if the PaO2/FiO2 ratio is low. The patient is not responding to treatment, and all options should be considered. The patient remains at risk for skin breakdown due to immobility; during proning, the risk is in the dependent areas such as the face. Proning is a labor-intensive procedure, and the nurse needs help from team members to ensure a safe turn, including protecting the airway. Continuous lateral rotation is a therapy done in the supine position with a specialized bed.

DIF: Cognitive Level: Application REF: p. 412

OBJ: Discuss medical management of the patient with acute respiratory failure.

TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity

27. The etiology of noncardiogenic pulmonary edema in acute respiratory distress syndrome (ARDS) is related to damage to the:

a.

alveolar-capillary membrane.

b.

left ventricle.

c.

mainstem bronchus.

d.

trachea.

ANS: A

Damage to the alveolar-capillary membrane results in noncardiogenic pulmonary edema. None of the other responses apply.

DIF: Cognitive Level: Comprehension REF: p. 401

OBJ: Describe the pathophysiology of ARF.

TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

MULTIPLE RESPONSE

1. Identify diagnostic criteria for ARDS. (Select all that apply.)

a.

Bilateral infiltrates on chest x-ray study

b.

Decreased cardiac output

c.

PaO2/ FiO2 ratio of less than 200

d.

Pulmonary artery occlusion pressure (PAOP) of more than 18 mm Hg

ANS: A, C

Diagnostic criteria for ARDS include bilateral infiltrates, or white out, on chest x-ray study and a low PaO2/FiO2 ratio. Decreased cardiac output and a high PAOP are seen in pulmonary edema associated with cardiac causes. Decreased cardiac output and a high PAOP are seen in pulmonary edema associated with cardiac causes.

DIF: Cognitive Level: Comprehension REF: pp. 407-408

OBJ: Formulate a plan of care for the patient with ARF.

TOP: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

2. Which of the following statements is true regarding oral care for the prevention of ventilator-associated pneumonia (VAP)? (Select all that apply.)

a.

Tooth brushing is performed every 2 hours for the greatest effect.

b.

Implementing a comprehensive oral care program is an intervention for preventing VAP.

c.

Oral care protocols should include oral suctioning and brushing teeth.

d.

Protocols that include chlorhexidine gluconate have been effective in preventing VAP.

ANS: B, C, D

A comprehensive oral care protocol is an intervention for preventing VAP. It includes oral suction, brushing teeth every 12 hours, and swabbing. Chlorhexidine gluconate has been effective in patients who have undergone cardiac surgery.

DIF: Cognitive Level: Application REF: p. 422 | Box 14-4 | Box 14-5

OBJ: Formulate a plan of care for the patient with ARF.

TOP: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity

3. Which of the following are physiological effects of positive end-expiratory pressure (PEEP) used in the treatment of ARDS? (Select all that apply.)

a.

Increase functional residual capacity

b.

Prevent collapse of unstable alveoli

c.

Improve arterial oxygenation

d.

Open collapsed alveoli

ANS: A, B, C, D

Ventilatory support for ARDS typically includes PEEP to restore functional residual capacity, open collapsed alveoli, prevent collapse of unstable alveoli, and improve arterial oxygenation.

DIF: Cognitive Level: Comprehension REF: p. 410, 412

OBJ: Discuss medical management of the patient with ARF.

TOP: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

4. Which of the following are components of the Institute for Healthcare Improvements (IHIs) ventilator bundle? (Select all that apply.)

a.

Interrupt sedation each day to assess readiness to extubate.

b.

Maintain head of bed at least 30 degrees elevation.

c.

Provide deep vein thrombosis prophylaxis.

d.

Provide prophylaxis for peptic ulcer disease.

e.

Swab the mouth with foam swabs every 2 hours.

ANS: A, B, C, D

Options A, B, C, and D are components of the IHI ventilator bundle. Oral care with chlorhexidine has recently been added to the IHI bundle. Swabbing alone provides comfort care.

DIF: Cognitive Level: Application REF: p. 422 | Box 14-4 | Box 14-5

OBJ: Formulate a plan of care for the patient with ARF.

TOP: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

5. Select the strategies for preventing deep vein thrombosis (DVT) and pulmonary embolus (PE). (Select all that apply.)

a.

Graduated compression stockings

b.

Heparin or lowmolecular weight heparin for patients at risk

c.

Sequential compression devices

d.

Strict bed rest

ANS: A, B, C

Graduated compression stockings, sequential compression devices, and anticoagulation can reduce the risk for DVT. Physical activity can also reduce the risk; bed rest increases the risk.

DIF: Cognitive Level: Comprehension REF: p. 425

OBJ: Formulate a plan of care for the patient with ARF.

TOP: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

6. The nurse is caring for a mechanically ventilated patient. The nurse understands that strategies to prevent ventilator-associated pneumonia include which of the following? (Select all that apply.)

a.

Drain condensate from the ventilator tubing away from the patient.

b.

Elevate the head of the bed 30 to 45 degrees.

c.

Instill normal saline as part of the suctioning procedure.

d.

Perform regular oral care with chlorhexidine.

ANS: A, B, D

Condensate should be drained away from the patient to avoid drainage back into the patients airway. Prevention guidelines recommend elevating the head of bed at 30 to 45 degrees. Regular antiseptic oral care, with an agent such as chlorhexidine, reduces oropharyngeal colonization. Normal saline is not recommended as part of the suctioning procedure, and it may increase the risk for infection.

DIF: Cognitive Level: Comprehension REF: p. 422 | Box 14-4 | Box 14-5

OBJ: Formulate a plan of care for the patient with ARF.

TOP: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

7. The nurse is caring for a patient in acute respiratory failure and understands that the patient should be positioned: (Select all that apply.)

a.

high Fowlers.

b.

side lying with head of bed elevated.

c.

sitting in a chair.

d.

supine with the bed flat.

ANS: A, B, C

Patients in respiratory distress are unable to tolerate a flat position. High Fowlers is appropriate. Side lying with head of bed elevated, sitting in a chair, and high Fowlers position are all appropriate ways to position the patient to facilitate gas exchange and comfort.

DIF: Cognitive Level: Comprehension REF: pp. 403-405

OBJ: Formulate a plan of care for the patient with ARF.

TOP: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

8. The nurse is caring for a patient with cystic fibrosis (CF) and understands that treatment consists of which of the following? (Select all that apply.)

a.

Airway clearance therapies

b.

Antibiotic therapy

c.

Nutritional support

d.

Tracheostomy

ANS: A, B, C

The three cornerstones of care for a patient with CF are antibiotic therapy, airway clearance, and nutritional support. A tracheostomy is not a standard treatment for CF.

DIF: Cognitive Level: Application REF: p. 427

OBJ: Discuss medical management of the patient with ARF.

TOP: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity

OTHER

1. On the following picture of the alveolar-capillary membrane, select the image that demonstrates shunting.

ANS:

C

Figure C shows a shunt. A is a normal alveolar-capillary unit. B is hypoventilation with increased PaCO2 and decreased PaO2. D is a ventilation/perfusion mismatch. E is a diffusion defect.

DIF: Cognitive Level: Comprehension REF: Figure 14-1

OBJ: Describe the pathophysiology of ARF. TOP: Nursing Process Step: N/A

MSC: NCLEX: Physiologic Integrity

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