Resp. Failure and ARDS - Questions

When assessing a patient with chronic obstructive pulmonary disease (COPD), the nurse finds a new onset of agitation and confusion. Which action should the nurse take first? a.Observe for facial symmetry. b.Notify the health care provider. c.Attempt to calm and reorient the patient. d.Assess oxygenation using pulse oximetry.

ANS: D Because agitation and confusion are frequently the initial indicators of hypoxemia, the nurse's initial action should be to assess O2 saturation. The other actions are also appropriate, but assessment of oxygenation takes priority over other assessments and notification of the health care provider.

A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation develops a right pneumothorax. Which collaborative action will the nurse anticipate next? a.Increase the tidal volume and respiratory rate. b.Decrease the fraction of inspired oxygen (FIO2). c.Perform endotracheal suctioning more frequently. d.Lower the positive end-expiratory pressure (PEEP).

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

Which nursing interventions included in the care of a mechanically ventilated patient with acute respiratory failure can the registered nurse (RN) delegate to an experienced licensed practical/vocational nurse (LPN/LVN) working in the intensive care unit? a.Assess breath sounds every hour. b.Monitor central venous pressures. c.Place patient in the prone position. d.Insert an indwelling urinary catheter.

ANS: D Insertion of indwelling urinary 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 central venous pressures require advanced assessment skills and should be done by the RN caring for a critically ill patient.

The nurse is providing care for an older adult patient who is experiencing low partial pressure of oxygen in arterial blood (PaO2) as a result of worsening left-sided pneumonia. Which intervention should the nurse use to help the patient mobilize his secretions? A. Augmented coughing or huff coughing B. Positioning the patient side-lying on his left side C. Frequent and aggressive nasopharyngeal suctioning D. Application of noninvasive positive pressure ventilation (NIPPV)

ANS: A Augmented coughing and huff coughing techniques may aid the patient in the mobilization of secretions. If positioned side-lying, the patient should be positioned on his right side (good lung down) for improved perfusion and ventilation. Suctioning may be indicated but should always be performed cautiously because of the risk of hypoxia. NIPPV is inappropriate in the treatment of patients with excessive secretions.

Which information about a patient who is receiving cisatracurium (Nimbex) to prevent asynchronous breathing with the positive pressure ventilator requires action by the nurse? a.No sedative has been ordered for the patient. b.The patient does not respond to verbal stimulation. c.There is no cough or gag reflex when the patient is suctioned. d.The patient's oxygen saturation remains between 90% to 93%.

ANS: A Because neuromuscular blockade is extremely anxiety provoking, it is essential that patients who are receiving neuromuscular blockade receive concurrent sedation and analgesia. Absence of response to stimuli is expected in patients receiving neuromuscular blockade. The O2 saturation is adequate.

A nurse is caring for a patient who is orally intubated and receiving mechanical ventilation. To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care? a.Elevate head of bed to 30 to 45 degrees. b.Give enteral feedings at no more than 10 mL/hr. c.Suction the endotracheal tube every 2 to 4 hours. d.Limit the use of positive end-expiratory pressure.

ANS: A Elevation of the head decreases the risk for aspiration. Positive end-expiratory pressure 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 patient's high energy needs.

The nurse in the cardiac care unit is caring for a patient who has developed acute respiratory failure. Which medication is used to decrease patient pulmonary congestion and agitation? A. Morphine B. Albuterol C. Azithromycin D. Methylprednisolone

ANS: A For a patient with acute respiratory failure related to the heart, morphine is used to decrease pulmonary congestion as well as anxiety, agitation, and pain. Albuterol is used to reduce bronchospasm. Azithromycin is used for pulmonary infections. Methylprednisolone is used to reduce airway inflammation and edema.

Which patient would most benefit from noninvasive positive pressure ventilation (NIPPV) to promote oxygenation? A. A patient whose cardiac output and blood pressure are unstable B. A patient whose respiratory failure is due to a head injury with loss of consciousness C. A patient with a diagnosis of cystic fibrosis and who is currently producing copious secretions D. A patient who is experiencing respiratory failure as a result of the progression of myasthenia gravis

ANS: D NIPPV such as continuous positive airway pressure (CPAP) is most effective in treating patients with respiratory failure resulting from chest wall and neuromuscular disease. It is not recommended in patients who are experiencing hemodynamic instability, decreased level of consciousness, or excessive secretions.

A 56-yr-old man with acute respiratory distress syndrome (ARDS) is on positive pressure ventilation (PPV). The patient's cardiac index is 1.4 L/min and pulmonary artery wedge pressure is 8 mm Hg. What order by the physician is important for the nurse to question? A. Initiate a dobutamine infusion at 3 mcg/kg/min. B. Administer 1 unit of packed red blood cells over the next 2 hours. C. Change the maintenance intravenous (IV) rate from 75 to 125 mL/hr. D. Increase positive end-expiratory pressure (PEEP) from 10 to 15 cm H2O.

ANS: D Patients on PPV and PEEP frequently experience decreased cardiac output (CO) and cardiac index (CI). High levels of PEEP increase intrathoracic pressure and cause decreased venous return which results in decreased CO. Interventions to improve CO include lowering the PEEP, administering crystalloid fluids or colloid solutions, and use of inotropic drugs (e.g., dobutamine, dopamine). Packed red blood cells may also be administered to improve CO and oxygenation if the hemoglobin is less than 9 or 10 mg/dL.

A patient develops increasing dyspnea and hypoxemia 2 days after heart surgery. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by heart failure, the nurse will plan to assist with a.obtaining a ventilation-perfusion scan. b.drawing blood for arterial blood gases. c.positioning the patient for a chest x-ray. d.insertion of a pulmonary artery catheter.

ANS: D 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.

A patient with acute respiratory distress syndrome (ARDS) and acute kidney injury has the following drugs ordered. Which drug should the nurse discuss with the health care provider before giving? a.gentamicin 60 mg IV b.pantoprazole (Protonix) 40 mg IV c.sucralfate (Carafate) 1 g per nasogastric tube d.methylprednisolone (Solu-Medrol) 60 mg IV

ANS: A 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 drugs are appropriate for the patient with ARDS.

When admitting a patient with possible respiratory failure and a high PaCO2, which assessment information should be immediately reported to the health care provider? a. The patient is very somnolent. b. The patient complains of weakness. c. The patient's blood pressure is 164/98. d. The patient's oxygen saturation is 90%.

ANS: A 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.

A patient is in acute respiratory distress syndrome (ARDS) as a result of sepsis. Which measure would be implemented to maintain cardiac output? A. Administer crystalloid fluids. B. Position the patient in the Trendelenburg position. C. Place the patient on fluid restriction and administer diuretics. D. Perform chest physiotherapy and assist with staged coughing.

ANS: A Low cardiac output may necessitate crystalloid fluids in addition to lowering positive end-expiratory pressure (PEEP) or administering inotropes. The Trendelenburg position (not recommended to treat hypotension) and chest physiotherapy are unlikely to relieve decreased cardiac output, and fluid restriction and diuresis would be inappropriate interventions.

A nurse is caring for a patient with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation using synchronized intermittent mandatory ventilation (SIMV). The settings include fraction of inspired oxygen (FIO2) of 80%, tidal volume of 450, rate of 16/minute, and positive end-expiratory pressure (PEEP) of 5 cm. Which assessment finding is most important for the nurse to report to the health care provider? a.O2 saturation of 99% b.Heart rate 106 beats/minute c.Crackles audible at lung bases d.Respiratory rate 22 breaths/minute

ANS: A The FIO2 of 80% increases the risk for O2 toxicity. Because the patient's 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 be the most important data to report to the health care provider.

The nurse is caring for a patient who arrived in the emergency department with acute respiratory distress. Which assessment finding by the nurse requires the most rapid action? a.The patient's PaO2 is 45 mm Hg. b.The patient's PaCO2 is 33 mm Hg. c.The patient's respirations are shallow. d.The patient's respiratory rate is 32 breaths/min.

ANS: A 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 patient's poor oxygenation.

The nurse is caring for a patient who is intubated and receiving positive pressure ventilation to treat acute respiratory distress syndrome (ARDS). Which finding is most important to report to the health care provider? a.Red-brown drainage from nasogastric tube b.Blood urea nitrogen (BUN) level 32 mg/dL c.Scattered coarse crackles heard throughout lungs d.Arterial blood gases: pH of 7.31, PaCO2 of 50, and PaO2 of 68

ANS: A The nasogastric drainage indicates possible gastrointestinal bleeding or stress ulcer and should be reported. The pH and PaCO2 are slightly abnormal, but current guidelines advocating for permissive hypercapnia indicate that these would not indicate an immediate need for a change in therapy. The BUN is slightly elevated but does not indicate an immediate need for action. Adventitious breath sounds are commonly heard in patients with ARDS.

A nurse is caring for an obese patient with right lower lobe pneumonia. Which position will be best to improve gas exchange? a.On the left side c.In the tripod position b.On the right side d.In the high-Fowler's position

ANS: A The patient should be positioned with the "good" lung in the dependent position to improve the match between ventilation and perfusion. The obese patient's abdomen will limit respiratory excursion when sitting in the high-Fowler's or tripod positions.

The patient has pulmonary fibrosis and experiences hypoxemia during exercise but not at rest. To plan patient care, the nurse should know the patient is experiencing which physiologic mechanism of respiratory failure? A. Diffusion limitation B. Intrapulmonary shunt C. Alveolar hypoventilation D. Ventilation-perfusion mismatch

ANS: A The patient with pulmonary fibrosis has a thickened alveolar-capillary interface that slows gas transport, and hypoxemia is more likely during exercise than at rest. Intrapulmonary shunt occurs when alveoli fill with fluid (e.g., acute respiratory distress syndrome, pneumonia). Alveolar hypoventilation occurs when there is a generalized decrease in ventilation (e.g., restrictive lung disease, central nervous system diseases, neuromuscular diseases). Ventilation-perfusion mismatch occurs when the amount of air does not match the amount of blood that the lung receives (e.g., chronic obstructive pulmonary disease, pulmonary embolus).

When prone positioning is used for a patient with acute respiratory distress syndrome (ARDS), which information obtained by the nurse indicates that the positioning is effective? a.The patient's PaO2 is 89 mm Hg, and the SaO2 is 91%. b.Endotracheal suctioning results in clear mucous return. c.Sputum and blood cultures show no growth after 48 hours. d.The skin on the patient's back is intact and without redness.

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

A patient admitted with acute respiratory failure has ineffective airway clearance related to thick secretions. Which nursing intervention would specifically address this patient problem? a.Encourage use of the incentive spirometer. b.Offer the patient fluids at frequent intervals. c.Teach the patient the importance of ambulation. d.Titrate oxygen level to keep O2 saturation above 93%.

ANS: B Because 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. Patients should be instructed to use the incentive spirometer on a regular basis (e.g., every hour) to facilitate the clearance of the secretions. The other actions may also be helpful in improving the patient's gas exchange, but they do not address the thick secretions that are causing the poor airway clearance.

Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the patient's caregiver is accurate? a."PEEP will push more air into the lungs during inhalation." b."PEEP prevents the lung air sacs from collapsing during exhalation." c."PEEP will prevent lung damage while the patient is on the ventilator." d."PEEP allows the breathing machine to deliver 100% O2 to the lungs."

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

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%. Which action should the nurse take? a.Suction the patient's oropharynx. b.Increase the prescribed O2 flow rate. c.Instruct the patient to cough and deep breathe. d.Help the patient to sit in a more upright position.

ANS: B Increasing O2 flow rate will usually improve O2 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.

When caring for older adult patients with respiratory failure, the nurse will add which intervention to individualize care? A. Position the patient in the supine position primarily. B. Assess frequently for signs and symptoms of delirium. C. Provide early endotracheal intubation to reduce complications. D. Delay activity and ambulation to provide additional healing time.

ANS: B Older adult patients are more predisposed to factors such as delirium, health care associated infections, and polypharmacy. Individualizing the older patient's care plan to address these factors will improve care. Older adult patients are not required to remain in a supine position only and should increase activity as soon as stability is determined. Endotracheal intubation is not provided early, and noninvasive positive pressure ventilation may be considered as an alternative. The nurse should consider that the aging process leads to decreased lung elastic recoil, weakened lung muscles and reduced gas exchange, which may make the patient difficult to wean from the ventilator.

When caring for a patient with acute respiratory distress syndrome (ARDS), which finding indicates therapy is appropriate? A. pH is 7.32. B. PaO2 is greater than or equal to 60 mm Hg. C. PEEP increased to 20 cm H2O caused BP to fall to 80/40. D. No change in PaO2 when patient is turned from supine to prone position

ANS: B The overall goal in caring for the patient with ARDS is for the PaO2 to be greater than or equal to 60 mm Hg with adequate lung ventilation to maintain a normal pH of 7.35 to 7.45. PEEP is usually increased for ARDS patients, but a dramatic reduction in BP indicates a complication of decreased cardiac output. A positive occurrence is a marked improvement in PaO2 from perfusion better matching ventilation when the anterior air-filled, nonatelectatic alveoli become dependent in the prone position.

The oxygen saturation (SpO2) for a patient with left lower lobe pneumonia is 90%. The patient has wheezes, a weak cough effort, and complains of fatigue. Which action should the nurse take next? a.Position the patient on the left side. b.Assist the patient with staged coughing. c.Place a humidifier in the patient's room. d.Schedule a 4-hour rest period for the patient.

ANS: B The patient's assessment indicates that assisted coughing is needed to help remove secretions, which will improve oxygenation. A 4-hour rest period at this time may allow the O2 saturation to drop further. Humidification will not be helpful unless the secretions can be mobilized. Positioning on the left side may cause a further decrease in oxygen saturation because perfusion will be directed more toward the more poorly ventilated lung.

A patient with respiratory failure has a respiratory rate of 6 breaths/min and an oxygen saturation (SpO2) of 88%. The patient is increasingly lethargic. Which intervention will the nurse anticipate? a.Administration of 100% O2 by non-rebreather mask b.Endotracheal intubation and positive pressure ventilation c.Insertion of a mini-tracheostomy with frequent suctioning d.Initiation of continuous positive pressure ventilation (CPAP)

ANS: B The patient's lethargy, low respiratory rate, and SpO2 indicate the need for mechanical ventilation with ventilator-controlled respiratory rate. Giving high-flow O2 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. CPAP requires that the patient initiate an adequate respiratory rate to allow adequate gas exchange.

The nurse reviews the electronic health record for a patient scheduled for a total hip replacement. Which assessment data shown in the accompanying figure increase the patient's risk for respiratory complications after surgery? History: age 81, Recent 15lb weight loss, knee arthroscopy 3 months ago Labs: Hgb 11.8, Hct 38%, Albumin 2.7 Phys Assessment: Lungs sound clear, mildly confused, disoriented to date, oriented to person and place a.Older age and anemia b.Albumin level and weight loss c.Recent arthroscopic procedure d.Confusion and disorientation to time

ANS: B The patient's recent weight loss and low protein stores indicate possible muscle weakness, which make it more difficult for an older patient to recover from the effects of general anesthesia and immobility associated with the hip surgery. The other information will also be noted by the nurse but does not place the patient at higher risk for respiratory failure.

A nurse is caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP). Which assessment finding by the nurse indicates that the PEEP may need to be reduced? a.The patient's PaO2 is 50 mm Hg and the SaO2 is 88%. b.The patient has subcutaneous emphysema on the upper thorax. c.The patient has bronchial breath sounds in both the lung fields. d.The patient has a first-degree atrioventricular heart block with a rate of 58 beats/min.

ANS: B 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 specific indications that PEEP should be reduced.

Which actions should the nurse start to reduce the risk for ventilator-associated pneumonia (VAP) (select all that apply)? a.Obtain arterial blood gases daily. b.Provide a "sedation holiday" daily. c.Give prescribed pantoprazole (Protonix). d.Elevate the head of the bed to at least 30°. e.Provide oral care with chlorhexidine (0.12%) solution daily.

ANS: B, C, D, E All of these interventions are part of the ventilator bundle that is recommended to prevent VAP. Arterial blood gases may be done daily but are not always necessary and do not help prevent VAP.

The nurse is caring for a 27-yr-old man with multiple fractured ribs from a motor vehicle crash. Which clinical manifestation, if experienced by the patient, is an early indication that the patient is developing respiratory failure? A. Tachycardia and pursed lip breathing B. Kussmaul respirations and hypotension C. Frequent position changes and agitation D. Cyanosis and increased capillary refill time

ANS: C A change in mental status is an early indication of respiratory failure. The brain is sensitive to variations in oxygenation, arterial carbon dioxide levels, and acid-base balance. Restlessness, confusion, agitation, and combative behavior suggest inadequate oxygen delivery to the brain.

During change-of-shift report on a medical unit, the nurse learns that a patient with aspiration pneumonia who was admitted with respiratory distress has become increasingly agitated. Which action should the nurse take first? a.Give the prescribed PRN sedative drug. b.Offer reassurance and reorient the patient. c.Use pulse oximetry to check the oxygen saturation. d.Notify the health care provider about the patient's status.

ANS: C Agitation may be an early indicator of hypoxemia. The other actions may also be appropriate, depending on the findings about O2 saturation.

Which diagnostic test will provide the nurse with the most specific information to evaluate the effectiveness of interventions for a patient with ventilatory failure? a.Chest x-ray b.O2 saturation c.Arterial blood gas analysis d.Central venous pressure monitoring

ANS: C Arterial blood gas (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 may also be done to help in assessing oxygenation or determining the cause of the patient's ventilatory failure.

The nurse is caring for a 37-yr-old female patient with multiple musculoskeletal injuries who has developed acute respiratory distress syndrome (ARDS). Which intervention should the nurse initiate to prevent stress ulcers? A. Observe stools for frank bleeding and occult blood. B. Maintain head of the bed elevation at 30 to 45 degrees. C. Begin enteral feedings as soon as bowel sounds are present. D. Administer prescribed lorazepam (Ativan) to reduce anxiety.

ANS: C Stress ulcers prevention includes early initiation of enteral nutrition to protect the gastrointestinal (GI) tract from mucosal damage. Antiulcer agents such as histamine (H2)-receptor antagonists, proton pump inhibitors, and mucosal protecting agents are also indicated to prevent stress ulcers. Monitoring for GI bleeding does not prevent stress ulcers. Ventilator-associated pneumonia related to aspiration is prevented by elevation of the head of bed to 30 to 45 degrees Stress ulcers are not caused by anxiety. Stress ulcers are related to GI ischemia from hypotension, shock, and acidosis.

Arterial blood gas results are reported to the nurse for a 68-yr-old patient admitted with pneumonia: pH 7.31, PaCO2 49 mm Hg, HCO3 26 mEq/L, and PaO2 52 mm Hg. What order should the nurse complete first? A. Administer albuterol inhaler prn. B. Increase fluid intake to 2500 mL per 24 hours. C. Initiate oxygen at 2 liters/minute by nasal cannula. D. Perform chest physical therapy four times per day.

ANS: C The arterial blood gas results indicate the patient is in uncompensated respiratory acidosis with moderate hypoxemia. Oxygen therapy is indicated to correct hypoxemia secondary to V/Q mismatch. Supplemental oxygen should be initiated at 1 to 3 L/min by nasal cannula, or 24% to 32% by simple face mask or Venturi mask to improve the PaO2. Albuterol would be administered next if needed for bronchodilation. Hydration is indicated for thick secretions, and chest physical therapy is indicated for patients with 30 mL or more of sputum production per day.

The nurse assesses vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature of 101.2° F, blood pressure of 90/56 mm Hg, pulse of 92 beats/min, and respirations of 34 breaths/min. Which action should the nurse take next? a.Give the scheduled IV antibiotic. b.Give the PRN acetaminophen (Tylenol). c.Obtain oxygen saturation using pulse oximetry. d.Notify the health care provider of the patient's vital signs.

ANS: C The patient's 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. Giving the scheduled antibiotic and the PRN acetaminophen will also be done, but they are not the highest priority for a patient who may be developing ARDS.

The nurse is caring for an older patient who was hospitalized 2 days earlier with community-acquired pneumonia. Which assessment information is most important to communicate to the health care provider? a.Persistent cough of blood-tinged sputum. b.Scattered crackles in the posterior lung bases. c.Oxygen saturation 90% on 100% O2 by nonrebreather mask. d.Temperature 101.5° F (38.6° C) after 2 days of IV antibiotics.

ANS: C The patient's low SpO2 despite receiving a high fraction of inspired oxygen (FIO2) indicates the possibility of acute respiratory distress syndrome (ARDS). The patient's 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.

The nurse is caring for a patient who is admitted with a barbiturate overdose. The patient is comatose with a blood pressure of 90/60 mm Hg, apical pulse of 110 beats/min, and respiratory rate of 8 breaths/min. Based on the initial assessment findings, the nurse recognizes that the patient is at risk for which type of respiratory failure? A. Hypoxemic respiratory failure related to shunting of blood B. Hypoxemic respiratory failure related to diffusion limitation C. Hypercapnic respiratory failure related to alveolar hypoventilation D. Hypercapnic respiratory failure related to increased airway resistance

ANS: C The patient's respiratory rate is decreased as a result of barbiturate overdose, which caused respiratory depression. The patient is at risk for hypercapnic respiratory failure due to an obtunded airway causing decreased respiratory rate and thus decreased CO2 elimination. Barbiturate overdose does not lead to shunting of blood, diffusion limitations, or increased airway resistance.

The nurse is admitting a 45-yr-old patient with asthma in acute respiratory distress. The nurse auscultates the patient's lungs and notes cessation of the inspiratory wheezing. The patient has not yet received any medication. What should this finding suggest to the nurse? A. Spontaneous resolution of the acute asthma attack B. An acute development of bilateral pleural effusions C. Airway constriction requiring immediate interventions D. Overworked intercostal muscles resulting in poor air exchange

ANS: C When a patient in respiratory distress has inspiratory wheezing and then it ceases, it is an indication of airway obstruction. This finding requires emergency action to restore airway patency. Cessation of inspiratory wheezing does not indicate spontaneous resolution of the acute asthma attack, bilateral pleural effusion development, or overworked intercostal muscles in this asthmatic patient that is in acute respiratory distress.

A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department complaining of shortness of breath and dyspnea on minimal exertion. 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 patient's pulse oximetry indicates a 91% O2 saturation. d.The patient's respirations have dropped to 10 breaths/minute.

ANS: D A drop 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 O2 saturation of 91% is common in patients with COPD and will provide adequate gas exchange and tissue oxygenation.

A 72-yr-old woman with aspiration pneumonia develops severe respiratory distress. Her PaO2 is 42 mmHg and FIO2 is 80%. Which intervention should the nurse complete first? A. Stat portable chest radiography B. Administer lorazepam (Ativan) 1 mg IV push C. Place the patient in a prone position on a rotational bed D. Position the patient with arms supported away from the chest

ANS: D The nurse will first position the patient to facilitate ventilation. Additional oxygen support may be necessary. Refractory hypoxemia indicates the patient is not demonstrating acute lung injury but has now developed acute respiratory distress syndrome (ARDS). If the PaO2 is 42 mm Hg on 80% FIO2 (fraction of inspired oxygen; room air is 21% FIO2), then the PaO2/FIO2 ratio is 52.5, indicating ARDS (PaO2/FIO2 ratio < 200). Stat portable chest radiography may show worsening infiltrates or "white lung." A rotational bed placing the patient in prone position would be a strategy to use for select patients with ARDS. This patient's age, diagnosis, and comorbidities may indicate appropriateness for this treatment. Administration of lorazepam (Ativan) 1 mg may be harmful to this patient's oxygenation status. Further assessment would be needed to determine safety.

After receiving change-of-shift report on a medical unit, which patient should the nurse assess first? a.A patient with cystic fibrosis who has thick, green-colored sputum b.A patient with pneumonia who has crackles bilaterally in the lung bases c.A patient with emphysema who has an oxygen saturation of 90% to 92% d.A patient with septicemia who has intercostal and suprasternal retractions

ANS: D This patient's history of septicemia and labored breathing suggest the onset of ARDS, which will require rapid interventions such as administration of O2 and use of positive-pressure ventilation. The other patients should also be assessed, but their assessment data are typical of their disease processes and do not suggest deterioration in their status.