Respiratory Failure
The nurse would identify which body systems as directly involved in the process of normal gas exchange? (Select all that apply.) Neurologic Endocrine Pulmonary Immune Cardiovascular Hepatic
Neurologic, Pulmonary, Cardiovascular See Lewis for systems directly involved in normal gas exchange
A 5-month-old infant is admitted with a diagnosis of respiratory syncytial virus (RSV) infection. The infant's condition suddenly deteriorates, and a dose of epinephrine is prescribed to relieve bronchospasm. For what side effect of the medication should the nurse assess the infant? a Tachycardia b Hypotension c Respiratory arrest d Central nervous system depression
A Epinephrine stimulates beta- and alpha-receptors; its actions include increasing heart rate and blood pressure and inducing bronchodilation. Increased blood pressure, not hypotension, is a potential side effect. Epinephrine relieves respiratory problems; it does not cause respiratory arrest. Epinephrine stimulates, not depresses, the central nervous system.
Which statement appropriately describes tidal volume? a It is the volume of air inhaled and exhaled with each breath. b It is the amount of air remaining in the lungs after forced expiration. c It is the additional air that can be forcefully inhaled after normal inhalation. d It is the additional air that can be forcefully exhaled after normal exhalation.
A Tidal volume is the volume of air inhaled and exhaled with each breath. Residual volume is the amount of air remaining in the lungs after forced expiration. Inspiratory reserve volume is the additional air that can be forcefully inhaled after normal inhalation. Expiratory reserve volume is the additional air that can be forcefully exhaled after normal exhalation.
A client is admitted to the intensive care unit with acute pulmonary edema. Which diuretic does the nurse anticipate will be prescribed? a Furosemide b Chlorothiazide c Spironolactone d acetazolamide
A Furosemide acts on the loop of Henle by increasing the excretion of chloride and sodium, is available for intravenous administration, and is more effective than chlorothiazide, spironolactone, and acetazolamide. Although used in the treatment of edema and hypertension, chlorothiazide is not as efficacious as furosemide. Spironolactone is a potassium-sparing diuretic; it is less efficacious than thiazide diuretics. Acetazolamide is used in the treatment of glaucoma to lower intraocular pressure.
You are caring for a patient with emphysema and respiratory failure who is receiving mechanical ventilation through an endotracheal tube. To prevent ventilator-associated pneumonia (VAP), which action is most important to include in the plan of care? a Administer ordered antibiotics as scheduled. b Hyperoxygenate the patient before suctioning. c Maintain the head of bed at a 30- to 45-degree angle. d Suction the airway when coarse crackles are audible.
C Research indicates that nursing actions such as maintaining the head of the bed at 30 to 45 degrees decrease the incidence of VAP. These actions are part of the standard of care for patients who require mechanical ventilation. The other actions are also appropriate for this patient but will not decrease the incidence of VAP.
. The patient with respiratory failure has an ABG result indicating respiratory acidosis. Which change in patient condition would you expect to correct this problem? a The patient receives a decrease in oxygen concentration. b The patient decreases respiratory rate from 12 to 6 breaths per minute. c The patient receives an increase in oxygen concentration. d The patient increases respiratory rate from 6 to 12 breaths per minute.
D Increasing respiratory rate will "blow off" additional CO2 resulting in a corrected ABG.
After change of shift, you are assigned to care for the following patients. Which patient should you assess first? a 68-year-old patient on a ventilator for whom a sterile sputum specimen must be sent to the laboratory. b 72-year-old with pneumonia who needs to be started on IV antibiotics. c 57-year-old with COPD and a pulse oximetry reading from the previous shift of 90% saturation. d 51-year-old with asthma who reports shortness of breath after using a bronchodilator inhaler.
D The patient with asthma did not achieve relief from shortness of breath after using the bronchodilator and is at risk for respiratory complications. This patient's needs are urgent.
A 4-month-old infant is admitted to the pediatric unit with severe tachypnea, flaring of the nares, wheezing, and irritability. The parents are told that the child has bronchiolitis and needs to be hospitalized for observation and treatment. While assessing the infant, the nurse determines that the infant is in respiratory failure. What clinical finding supports the nurse's conclusion? Wheezing cough Intercostal retractions Fine crackles on deep inspiration Sudden absence of breath sounds
D A sudden absence of breath sounds occurs when bronchioles become obstructed and respiratory failure is imminent. A wheezing cough is a common manifestation of bronchiolitis and is caused by the passage of air through the narrowed airways; it does not herald respiratory failure. Intercostal retractions occur with mild and moderate respiratory distress in infants. Fine crackles are a routine occurrence with bronchiolitis, not a sign of respiratory failure.
An infant with cardiopulmonary disease who displays signs and symptoms of bronchiolitis and pneumonia was admitted to the hospital. What condition is the infant likely to have? a Poliomyelitis b Pneumococcal infection c Meningococcal infection d Respiratory syncytial virus infection
D Respiratory syncytial virus infections are the most common cause for hospitalization of infants younger than 1 year of age; this disease especially affects premature infants and infants with cardiopulmonary disease. Poliomyelitis is caused by the poliovirus. Streptococcus pneumonia infections cause meningitis, sepsis, pneumonia, and otitis media. Neisseria meningitidis causes meningitis.
After change of shift, you are assigned to care for the following patients. Which patient should you assess first? a 68-year-old patient on a ventilator for whom a sterile sputum specimen must be sent to the laboratory b 57-year-old with COPD and a pulse oximetry reading from the previous shift of 90% saturation c 72-year-old with pneumonia who needs to be started on IV antibiotics d 51-year-old with asthma who reports shortness of breath after using a bronchodilator inhaler
D The patient with asthma did not achieve relief from shortness of breath after using the bronchodilator and is at risk for respiratory complications. This patient's needs are urgent. The other patients need to be assessed as soon as possible, but none of their situations is urgent. In COPD patients, pulse oximetry oxygen saturations of more than 90% are acceptable.
When assessing a 22-year-old patient who required emergency surgery and multiple transfusions 3 days ago, you find that the patient looks anxious and has labored respirations at a rate of 38 breaths/min. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most appropriate? a Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes. b Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs. c Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation. d Switch the patient to a nonrebreather mask at 95% to 100% FIO2 and call the physician to discuss the patient's status.
D The patient's history and symptoms suggest the development of ARDS, which will require intubation and mechanical ventilation. The maximum oxygen delivery with a nasal cannula is an Fi o 2 of 44%. This is achieved with the oxygen flow at 6 L/min, so increasing the flow to 10 L/min will not be helpful. Helping the patient to cough and deep breathe will not improve the lung stiff ness that is causing his respiratory distress. Morphine sulfate will only decrease the respiratory drive and further contribute to his hypoxemia.
The acid-base status of a patient is dependent on normal gas exchange. Which patient would the nurse identify as having an increased risk for the development of respiratory acidosis? a A patient with chronic lung disease with increased carbon dioxide retention b acute anxiety, hyperventilation, and decreased carbon dioxide retention c decreased cardiac output with increased serum lactic acid production d gastric drainage with increased removal of gastric acid
A An increase in C02 retention will lead to respiratory acidosis.
A patient has chronic obstructive pulmonary disease (COPD). Which intervention for airway management should you delegate to the unlicensed assistive personnel (UAP)? a Assisting the patient to sit up on the side of the bed. b Instructing the patient to cough effectively. c Auscultating breath sounds every 4 hours.
A Assisting patients with positioning and ADL's is within the educational preparation and scope of practice of UAP's.
A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by nonrebreather mask, but arterial blood gas measurements still show poor oxygenation. As the nurse responsible for this patient's care, you would anticipate a physician order for what action? a Perform endotracheal intubation and initiate mechanical ventilation. b Immediately begin continuous positive airway pressure (CPAP) via the patient's nose and mouth. c Administer furosemide 100 mg IV push immediately (STAT). d Call a code for respiratory arrest.
A A nonrebreather mask can deliver nearly 100% oxygen. When the patient's oxygenation status does not improve adequately in response to delivery of oxygen at this high concentration, refractory hypoxemia is present. Usually at this stage, the patient is working very hard to breathe and may go into respiratory arrest unless health care providers intervene by providing intubation and mechanical ventilation to decrease the patient's work of breathing.
Which patient is at highest risk for hypoxemic respiratory failure? a A patient who has fractured ribs and a flail chest b A patient who has a massive pulmonary embolism c A patient who has respiratory muscle paralysis d A patient who has slow breathing from a drug overdose
B Hypoxemic respiratory failure is also referred to as oxygenation failure because the primary problem is inadequate O2 transfer between the alveoli and the pulmonary capillary bed. A massive pulmonary embolism is an example of a cause of hypoxemic respiratory failure. This is the only patient among the choices who has hypoxemic respiratory failure.
A client with a history of emphysema develops a respiratory infection and is admitted to the hospital in acute respiratory distress. The client's arterial blood studies indicate pH 7.30, PO2 60 mm Hg, PCO2 55 mm Hg, and HCO3 23 mEq/L (23 mmol/L). How should the nurse interpret these findings? a Metabolic acidosis b Respiratory acidosis c Compensated respiratory acidosis d Compensated metabolic acidosis
B The pH is less than the norm of 7.35 to 7.45, indicating acidosis [1] [2] [3]. The PO2 is less than the norm of 80 to 100 mm Hg. The PCO2 is increased more than the norm of 35 to 45 mm Hg. The HCO3 is within the norm of 21 to 28 mEq/L (21 to 28 mmol/L). These results indicate a respiratory etiology.
The nurse is assessing a patient for the adequacy of ventilation. What assessment findings would indicate the patient has good ventilation? (Select all that apply.) a Respiratory rate is 24 breaths/min. b Oxygen saturation level is 98%. c The right side of the thorax expands slightly more than the left. d Trachea is just to the left of the sternal notch. e Nail beds are pink with good capillary refill. f There is presence of quiet, effortless breath sounds at lung base bilaterally.
B, E, F Oxygen saturation >97%, good cap refill, and quiet breath sounds are consistent with adequate ventilation.
The nurse is assigned a group of patients. Which patient would the nurse identify as being at increased risk for impaired gas exchange? A patient: a with a blood glucose of 350 mg/dL. b who has been on anticoagulants for 10 days. c with a hemoglobin of 8.5 g/dL d with a heart rate of 100 beats/min and blood pressure of 100/60
C A decrease in hemoglobin is equal to a decrease in our oxygen carrying capacity, which leads to impaired gas exchange.
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 patient's respiratory rate has decreased from 30 to 10 breaths/min. d The patient's pulse oximetry indicates an O2 saturation of 91%.
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.
A patient with severe chronic lung disease is hospitalized with respiratory distress. Which finding would suggest to the nurse that the patient has developed rapid decompensation? a An Spo2 of 86% b A blood pH of 7.33 c Agitation or confusion d Paco2 increases from 48 to 55 mm Hg
C It is especially important to monitor specific and nonspecific signs of respiratory failure in patients with chronic lung disease because a small change can cause significant decompensation. Immediately report any change in mental status, such as agitation, combative behavior, confusion, or decreased level of consciousness.
You are the preceptor for an RN who is undergoing orientation to the intensive care unit. The RN is providing care for a patient with ARDS who has just been intubated in preparation for mechanical ventilation. You observe the nurse perform all of these actions. For which action must you intervene immediately? a Assessing for bilateral breath sounds and symmetrical chest movement b Auscultating over the stomach to rule out esophageal intubation c Marking the tube 1 cm from where it touches the incisor tooth or nares d Ordering a chest radiograph to verify that tube placement is correct
C The endotracheal tube should be marked at the level where it touches the incisor tooth or nares. This mark is used to verify that the tube has not shifted. The other three actions are appropriate after endotracheal tube placement. The priority at this time is to verify that the tube has been correctly placed.