Chapter 68: Nursing Management: Respiratory Failure and Acute Respiratory Distress Syndrome My Nursing Test Banks

Lewis: Medical-Surgical Nursing, 8th Edition

Chapter 68: Nursing Management: Respiratory Failure and Acute Respiratory Distress Syndrome

Test Bank

MULTIPLE CHOICE

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

ANS: C

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 patients ventilatory failure.

DIF: Cognitive Level: Application REF: 1752-1754

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

2. While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patients oxygen saturation (SpO2) from 94% to 88%. The nurse will

a.

increase the oxygen flow rate.

b.

suction the patients oropharynx.

c.

assist the patient to cough and deep breathe.

d.

help the patient to sit in a more upright position.

ANS: A

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.

DIF: Cognitive Level: Application REF: 1747-1749 | 1754

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

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).

ANS: B

The patients 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 patients respiratory rate is so low. Insertion of a mini-tracheostomy will facilitate removal of secretions, but it will not improve the patients respiratory rate or oxygenation. BiPAP requires that the patient initiate an adequate respiratory rate to allow adequate gas exchange.

DIF: Cognitive Level: Application REF: 1754-1756 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

4. The pulse oximetry for a patient with right lower lobe pneumonia indicates an oxygen saturation of 90%. The patient has rhonchi, a weak cough effort, and complains of fatigue. Which action is best for the nurse to take?

a.

Position the patient on the right side.

b.

Place a humidifier in the patients room.

c.

Assist the patient with staged coughing.

d.

Schedule a 2-hour rest period for the patient.

ANS: C

The patients assessment indicates that assisted coughing is needed to help remove secretions, which will improve oxygenation. A 2-hour rest period at this time may allow the oxygen saturation to drop further. Humidification will not be helpful unless the secretions can be mobilized. Positioning on the right side may cause a further decrease in oxygen saturation because perfusion will be directed more toward the more poorly ventilated lung.

DIF: Cognitive Level: Application REF: 1754-1755

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

5. When the nurse is caring for an obese patient with left lower lobe pneumonia, gas exchange will be best when the patient is positioned

a.

on the left side.

b.

on the right side.

c.

in the tripod position.

d.

in the high-Fowlers position.

ANS: B

The patient should be positioned with the good lung in the dependent position to improve the match between ventilation and perfusion. The obese patients abdomen will limit respiratory excursion when sitting in the high-Fowlers or tripod positions.

DIF: Cognitive Level: Application REF: 1754-1755

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

6. 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 patients SpO2 is 90%.

c.

The patient complains of weakness.

d.

The patients blood pressure is 162/94.

ANS: A

Increasing somnolence will decrease the patients 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.

DIF: Cognitive Level: Application REF: 1751

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

7. A patient with acute respiratory distress syndrome (ARDS) and acute renal failure has the following medications prescribed. Which medication should the nurse discuss with the health care provider before administration?

a.

ranitidine (Zantac) 50 mg IV

b.

gentamicin (Garamycin) 60 mg IV

c.

sucralfate (Carafate) 1 g per nasogastric tube

d.

methylprednisolone (Solu-Medrol) 40 mg IV

ANS: B

Gentamicin, which is one of the aminoglycoside antibiotics, is potentially nephrotoxic, and the nurse should clarify the drug and dosage with the health care provider before administration. The other medications are appropriate for the patient with ARDS.

DIF: Cognitive Level: Application REF: 1761-1762

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

8. A patient develops increasing dyspnea and hypoxemia 2 days after having cardiac surgery. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by left ventricular failure, the nurse will anticipate assisting with

a.

inserting a pulmonary artery catheter.

b.

obtaining a ventilation-perfusion scan.

c.

drawing blood for arterial blood gases.

d.

positioning the patient for a chest radiograph.

ANS: A

Pulmonary artery wedge pressures are normal in the patient with ARDS because the fluid in the alveoli is caused by increased permeability of the alveolar-capillary membrane rather than by the backup of fluid from the lungs (as occurs in cardiogenic pulmonary edema). The other tests will not help in differentiating cardiogenic from noncardiogenic pulmonary edema.

DIF: Cognitive Level: Application REF: 1753-1754

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

9. Which assessment finding by the nurse when caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP) indicates that the PEEP may need to be decreased?

a.

The patient has subcutaneous emphysema.

b.

The patient has a sinus bradycardia with a rate of 52.

c.

The patients PaO2 is 50 mm Hg and the SaO2 is 88%.

d.

The patient has bronchial breath sounds in both the lung fields.

ANS: A

The subcutaneous emphysema indicates barotrauma caused by positive pressure ventilation and PEEP. Bradycardia, hypoxemia, and bronchial breath sounds are all concerns and will need to be addressed, but they are not indications that PEEP should be reduced.

DIF: Cognitive Level: Application REF: 1760-1761

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

10. Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the family members of a patient with ARDS is correct?

a.

PEEP will prevent fibrosis of the lung from occurring.

b.

PEEP will push more air into the lungs during inhalation.

c.

PEEP allows the ventilator to deliver 100% oxygen to the lungs.

d.

PEEP prevents the lung air sacs from collapsing during exhalation.

ANS: D

By preventing alveolar collapse during expiration, PEEP improves gas exchange and oxygenation. PEEP will not prevent the fibrotic changes that occur with ARDS, push more air into the lungs, or change the fraction of inspired oxygen (FIO2) delivered to the patient.

DIF: Cognitive Level: Comprehension REF: 1761-1762

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

11. When prone positioning is used in the care of a patient with acute respiratory distress syndrome (ARDS), which information obtained by the nurse indicates that the positioning is effective?

a.

The patients PaO2 is 90 mm Hg, and the SaO2 is 92%.

b.

Endotracheal suctioning results in minimal mucous return.

c.

Sputum and blood cultures show no growth after 24 hours.

d.

The skin on the patients back is intact and without redness.

ANS: A

The purpose of prone positioning is to improve the patients oxygenation as indicated by the PaO2 and SaO2. The other information will be collected but does not indicate whether prone positioning has been effective.

DIF: Cognitive Level: Application REF: 1762-1763 TOP: Nursing Process: Evaluation

MSC: NCLEX: Physiological Integrity

12. The nurse obtains the vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature 101.2 F, blood pressure 90/56 mm Hg, pulse 92, respirations 34. Which action should the nurse take next?

a.

Administer the scheduled IV antibiotic.

b.

Give the PRN acetaminophen (Tylenol) 650 mg.

c.

Obtain oxygen saturation using pulse oximetry.

d.

Notify the health care provider of the patients vital signs.

ANS: C

The patients increased respiratory rate in combination with the admission diagnosis of gram-negative sepsis indicates that acute respiratory distress syndrome (ARDS) may be developing. The nurse should check for hypoxemia, a hallmark of ARDS. The health care provider should be notified after further assessment of the patient. Administration of the scheduled antibiotic and administration of Tylenol also will be done, but they are not the highest priority for a patient who may be developing ARDS.

DIF: Cognitive Level: Application REF: 1758 | 1760

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

13. To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care for a patient who requires intubation and mechanical ventilation?

a.

Avoid use of positive end-expiratory pressure (PEEP).

b.

Suction every 2 hours.

c.

Elevate head of bed to 30 to 45 degrees.

d.

Give enteral feedings at no more than 10 mL/hr.

ANS: C

Elevation of the head decreases the risk for aspiration. PEEP is frequently needed to improve oxygenation in patients receiving mechanical ventilation. Suctioning should be done only when the patient assessment indicates that it is necessary. Enteral feedings should provide adequate calories for the patients high energy needs.

DIF: Cognitive Level: Application REF: 1760-1761 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

14. A patient has a nursing diagnosis of ineffective airway clearance related to thick, secretions. Which action will be best for the nurse to include in the plan of care?

a.

Encourage use of the incentive spirometer.

b.

Offer the patient fluids at frequent intervals.

c.

Teach the patient the importance of coughing.

d.

Increase oxygen level to keep O2 saturation >95%.

ANS: B

Since the reason for the poor airway clearance is the thick secretions, the best action will be to encourage the patient to improve oral fluid intake. The use of the incentive spirometer should be more frequent in order to facilitate the clearance of the secretions. The other actions also may be helpful in improving the patients gas exchange, but they do not address the thick secretions that are causing the poor airway clearance.

DIF: Cognitive Level: Application REF: 1755 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

15. A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation develops a pneumothorax. Which action will the nurse anticipate taking?

a.

Lower the positive end-expiratory pressure (PEEP).

b.

Increase the fraction of inspired oxygen (FIO2).

c.

Suction more frequently.

d.

Increase the tidal volume.

ANS: A

Because barotrauma is associated with high airway pressures, the level of PEEP should be decreased. The other actions will not decrease the risk for pneumothorax.

DIF: Cognitive Level: Application REF: 1760-1761 TOP: Nursing Process: Planning

MSC: NCLEX: Physiological Integrity

16. After receiving change-of-shift report, which patient will the nurse assess first?

a.

A patient with cystic fibrosis who has thick, green-colored sputum

b.

A patient with pneumonia who has coarse crackles in both lung bases

c.

A patient with emphysema who has an oxygen saturation of 91% to 92%

d.

A patient with septicemia who has intercostal and suprasternal retractions

ANS: D

This patients history of septicemia and labored breathing suggest the onset of ARDS, which will require rapid interventions such as administration of oxygen and use of positive pressure ventilation. The other patients also should be assessed as quickly as possible, but their assessment data are typical of their disease processes and do not suggest deterioration in their status.

DIF: Cognitive Level: Analysis REF: 1758-1760

OBJ: Special Questions: Multiple Patients

TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment

17. A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department complaining of shortness of breath and dyspnea. Which assessment finding by the nurse is most important to report to the health care provider?

a.

The patient has bibasilar lung crackles.

b.

The patient is sitting in the tripod position.

c.

The patients respiratory rate has decreased from 30 to 10 breaths/min.

d.

The patients pulse oximetry indicates an O2 saturation of 91%.

ANS: C

A decrease in respiratory rate in a patient with respiratory distress suggests the onset of fatigue and a high risk for respiratory arrest. Therefore immediate action such as positive pressure ventilation is needed. Patients who are experiencing respiratory distress frequently sit in the tripod position because it decreases the work of breathing. Crackles in the lung bases may be the baseline for a patient with COPD. An oxygen saturation of 91% is common in patients with COPD and will provide adequate gas exchange and tissue oxygenation.

DIF: Cognitive Level: Application REF: 1751-1752

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

18. When assessing a patient with chronic lung disease, the nurse finds a sudden onset of agitation and confusion. Which action should the nurse take first?

a.

Check pupil reaction to light.

b.

Notify the health care provider.

c.

Attempt to calm and reassure the patient.

d.

Assess oxygenation using pulse oximetry.

ANS: D

Since agitation and confusion are frequently the initial indicators of hypoxemia, the nurses initial action should be to assess oxygen saturation. The other actions also are appropriate, but assessment of oxygenation takes priority over other assessments and notification of the health care provider.

DIF: Cognitive Level: Application REF: 1750-1751

OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation

MSC: NCLEX: Physiological Integrity

19. The nurse is caring for a 22-year-old patient who came to the emergency department with acute respiratory distress. Which information about the patient requires the most rapid action by the nurse?

a.

Respiratory rate is 32 breaths/min.

b.

Pattern of breathing is shallow.

c.

The patients PaO2 is 45 mm Hg.

d.

The patients PaCO2 is 34 mm Hg.

ANS: C

The PaO2 indicates severe hypoxemia and respiratory failure. Rapid action is needed to prevent further deterioration of the patient. Although the shallow breathing, rapid respiratory rate, and low PaCO2 also need to be addressed, the most urgent problem is the patients poor oxygenation.

DIF: Cognitive Level: Application REF: 1746-1747

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

20. The nurse is caring for a patient who was hospitalized 2 days earlier with aspiration pneumonia. Which assessment information is most important to communicate to the health care provider?

a.

Cough that is productive of blood-tinged sputum

b.

Scattered crackles throughout the posterior lung bases

c.

Temperature of 101.5 F (38.6 C) after 2 days of IV antibiotic therapy

d.

Oxygen saturation (SpO2) has dropped to 90% with administration of 100% O2 by non-rebreather mask.

ANS: D

The patients low SpO2 despite receiving a high fraction of inspired oxygen (FIO2) indicates the possibility of acute respiratory distress syndrome (ARDS). The patients blood-tinged sputum and scattered crackles are not unusual in a patient with pneumonia, although they do require continued monitoring. The continued temperature elevation indicates a possible need to change antibiotics, but this is not as urgent a concern as the progression toward hypoxemia despite an increase in O2 flow rate.

DIF: Cognitive Level: Application REF: 1760

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

21. Which of these nursing actions included in the care of a mechanically ventilated patient with acute respiratory distress syndrome (ARDS) can the RN delegate to an experienced LPN/LVN working in the intensive care unit?

a.

Assess breath sounds

b.

Insert a retention catheter

c.

Place patient in the prone position

d.

Monitor pulmonary artery pressures

ANS: B

Insertion of retention catheters is included in LPN/LVN education and scope of practice and can be safely delegated to an LPN/LVN who is experienced in caring for critically ill patients. Placing a patient who is on a ventilator in the prone position requires multiple staff and should be supervised by an RN. Assessment of breath sounds and obtaining pulmonary artery pressures require advanced assessment skills and should be done by the RN caring for a critically ill patient.

DIF: Cognitive Level: Application REF: 1761-1763

OBJ: Special Questions: Delegation TOP: Nursing Process: Planning

MSC: NCLEX: Safe and Effective Care Environment

22. A patient with ARDS who is receiving mechanical ventilation using synchronized intermittent mandatory ventilation (SIMV) has settings of fraction of inspired oxygen (FIO2) 80%, tidal volume 500, rate 18, and positive end-expiratory pressure (PEEP) 5 cm. Which assessment finding is most important for the nurse to report to the health care provider?

a.

Oxygen saturation 99%

b.

Patient respiratory rate 22 breaths/min

c.

Crackles audible at lung bases

d.

Apical pulse rate 104 beats/min

ANS: A

The FIO2 of 80% increases the risk for oxygen toxicity. Since the patients O2 saturation is 99%, a decrease in FIO2 is indicated to avoid toxicity. The other patient data would be typical for a patient with ARDS and would not need to be urgently reported to the health care provider.

DIF: Cognitive Level: Analysis REF: 1760 | 1761-1762

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment

MSC: NCLEX: Physiological Integrity

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