Review Questions - Chapter 15 Assessment Performance 405b
The nurse is listening to a lecture on the physiological consequences of acute respiratory distress syndrome (ARDS). Which statement indicates that teaching has been effective? A. "ARDS is associated with decreased compliance." B. ARDS is associated with decreased physiological dead space." C. "ARDS is associated with increased resistance." D. "ARDS is associated with Pulmonary fibrosis."
"ARDS is associated with decreased compliance." ARDS is associated with decreased lung compliance.
The nurse is orienting a new RN in the care of a patient with respiratory distress due to emphysema. The patient is being treated with O2 via a Venturi mask with 35% oxygen. Which statement by the new RN indicates that teaching has been effective, when the nurse questions the new RN about the use of the Venturi mask? A. A nasal cannula will dry the mucous membranes and cause an increased risk of infection." B. "Her alveoli cannot absorb higher levels of O2 because of the emphysema." C. "Her alveoli have been damaged and may rupture with higher doses of O2." D. "Her respiratory center requires low O2 concentration to stimulate breathing."
"Her respiratory center requires low O2 concentration to stimulate breathing." In patients with COPD, the respiratory drive is stimulated by hypoxemia, not increased levels of carbon dioxide. Administration of oxygen in high levels will impair the respiratory drive.
The nurse is assessing a patient for a possible pulmonary embolus. Assessment findings may include which of the following? A. Acute onset of chest pain B. Hemoptysis C. Low oxygen saturation level D. Pleural friction rub
Acute onset of chest pain Hemoptysis Low oxygen saturation level Chest pain, hemoptysis, and a low oxygen saturation level are signs and symptoms of pulmonary embolus. A pleural friction rub is seen with disorders such as pleural effusion.
The nurse is caring for a patient with status asthmaticus in the emergency department. The nurse anticipates what therapies to be ordered? A. Inhaled anticholinergic agent B. Inhaled rapid-acting beta-2 agonists C. Oxygen administration D. Systemic corticosteroids
All are treatment of severe asthma exacerbation (Table 15-2).
Which of the following are nursing interventions to prevent ventilator-associated pneumonia (VAP)? A. Elevate the head of bed to at least 30 degrees. B. Intubate the patient with an endotracheal tube with continuous subglottic aspiration of secretions. C. Maintain a deep level of sedation. D. Provide regular oral care, including the use of chlorhexidine.
Elevate the head of bed to at least 30 degrees. Provide regular oral care, including the use of chlorhexidine. Maintaining the head of bed at 30 to 45 degrees and providing oral care are two interventions to prevent VAP that the nurse can implement. The special endotracheal tube reduces the risk for VAP; however, this is not a nursing intervention. The patient should be sedated based on specific targets. Deep sedation should be avoided because it prolongs time on mechanical ventilation, increasing the patient's risk for VAP.
Lung-protective strategies for mechanical ventilation to treat acute respiratory distress syndrome while also preventing complications include which of the following? A. High levels of sedation B. Low tidal volume of 6 mL/kg ideal body weight C. Oxygen levels (FiO2) 0.80-1.00 D. Positive end-expiratory pressure (PEEP) 25 cm H2O or higher
Low tidal volume of 6 mL/kg ideal body weight The target tidal volume is 6 mL/kg. High levels of sedation may be needed but are not a protective strategy. The target lung-protective oxygen level is 0.6. Lower levels of PEEP are desirable as the risk for barotrauma increases with higher levels of PEEP.
The nurse is drawing labs on a patient with COPD in the critical care unit. Which baseline arterial blood gases (ABGs) should the nurse expect for this patient? A. PaO2 50 mm Hg and PaCO2 35 mm Hg B. PaO2 55 mm Hg and PaCO2 55 mm Hg C. PaO2 80 mm Hg and PaCO2 50 mm Hg D. PaO2 75 mm Hg and PaCO2 40 mm Hg
PaO2 55 mm Hg and PaCO2 55 mm Hg The patient with COPD typically has hypoxemia and an elevated carbon dioxide level.
Which of the following treatments should the nurse anticipate administering to a hypoxic patient admitted with exacerbation of COPD? A. Bag-valve-mask ventilation with oxygen at 15 L/min B. Continuous positive airway pressure (CPAP) via face mask C. Non-rebreather mask with 80% oxygen D. Oxygen via Venturi mask at 40% oxygen
Oxygen via Venturi mask at 40% oxygen The initial treatment of hypoxemia is delivery of oxygen at a low flow rate. The Venturimask allows a designated percentage of oxygen to be delivered. The initial treatment is low-flow oxygen. If the patient fails to respond to this treatment, noninvasive ventilation (CPAP or BiPAP) may be indicated. A non-rebreather mask at 80% delivers a high percentage of oxygen, which may impair the patient's respiratory drive. Bag-valve-mask ventilation is not indicated. Question 8 of 12
A patient in acute respiratory failure is experiencing carbon dioxide narcosis secondary to increased CO2 retention. What assessment finding should the nurse expect? A. Nasal flaring B. Paradoxical respirations C. Somnolence D. Suprasternal muscle retractions
Somnolence Somnolence, lethargy, and coma are seen with CO2 retention. Nasal flaring, paradoxical respirations, and muscle retracts are seen with respiratory muscle fatigue (clinical alert).
A patient presents to the emergency department in acute respiratory distress. She has a long-standing history of COPD. Which of the following positions should the nurse place this patient in for optimal tissue perfusion? A. Prone on a stretcher B. In a recliner, leaning back as far as it will go C. Side-lying with head of bed at 15 degrees D. Stretcher with head of bed as high as it will go
Stretcher with head of bed as high as it will go A patient with COPD will be most comfortable in an upright position that facilitates lung expansion. Proning will not be tolerated, and a 15-degree elevation is not high enough. A recliner is sometimes helpful, but not leaning back as far as it will go.
The etiology of pulmonary edema in acute respiratory distress syndrome is related to: A. damage to the alveolar-capillary membrane. B. decreased cardiac output. C. tension pneumothorax D. volutrauma and hypoxemia.
damage to the alveolar -capillary membrane. Noncardiogenic pulmonary edema is seen in ARDS secondary to damage to the alveolar-capillary membrane. Decreased cardiac output, tension pneumothorax, volutrauma, and hypoxemia are not causes.
The nurse is caring for a patient at risk for respiratory failure. Which assessment findings would alert the nurse to potential respiratory failure? Anxiety and restlessness Cyanosis and hyperventilation Dyspnea and nasal flaring Hypertension and bradycardia
nxiety and restlessness Neurological changes, such as anxiety and restlessness, are early signs of hypoxemia in respiratory failure. Other early signs are tachycardia and increased blood pressure. Cyanosis, dyspnea, and nasal flaring are later signs.
