EAQ 2 - RESP. FAILURE, ARDS,VENTILATOR

Which is the normal ventilation to perfusion (V/Q) ratio? Record your answer using a whole number.

1 Rationale A match of ventilation and perfusion would result in a V/Q ratio of 1:1, which is expressed as V/Q = 1. When the match is not 1:1, a V/Q mismatch occurs. p. 1589

An arterial oxygen value (PaO 2) less than which number in millimeters of mercury indicates hypoxemic respiratory failure when a patient is receiving an inspired oxygen concentration of more than 60%? Record your answer using a whole number.

60 Rationale Hypoxemic respiratory failure is commonly defined as a PaO 2 of less than 60 mm Hg when the patient is receiving an inspired oxygen concentration of 60% or more. This definition incorporates two important concepts: first, the PaO 2 level indicates inadequate oxygen in the arterial blood; second, this PaO 2 level exists despite administration of supplemental oxygen at a percentage (60%) that is about three times that in room air (21%).

Which complication will the nurse monitor for when caring for a patient receiving mechanical ventilation with high levels of positive end-expiratory pressure (PEEP)? Barotrauma Oxygen toxicity Pneumoperitoneum Oversedation

Rationale A high level of PEEP leads to barotrauma due to the overdistention and rupture of alveoli. Oxygen toxicity may occur when a patient receives high oxygen concentrations for prolonged periods but is not a complication of PEEP. Pneumothorax may occur with PEEP, but pneumoperitoneum is not a complication of positive pressure ventilation or PEEP. Oversedation may occur with excessive use of sedative medications but is not a complication of PEEP. p. 1600

Which information will the nurse include when a patient with respiratory failure asks about the purpose of the prescribed arterial blood gases (ABGs)? Select all that apply. ABG testing is noninvasive. Acid-base balance changes are diagnosed with ABGs. Carbon dioxide level in the blood is determined by ABG testing. Arterial oxygen level can be accurately determined by ABG testing. When ABG results are normal, the patient's respiratory failure has resolved.

Rationale ABGs are used to assess changes in pH (acid-base status), arterial oxygen tension and saturation (PaO 2 and SaO 2), carbon dioxide (PaCO 2), and bicarbonate (HCO 3). ABG testing requires that blood be obtained from an arterial puncture and is invasive. Although ABG testing may indicate improvement in a patient's respiratory status, normal ABGs do not always indicate resolution of respiratory failure since patients may still require administration of high oxygen concentrations and mechanical ventilation to achieve normal ABGs. p. 1588

Which diagnostic testing will the nurse monitor to evaluate for adverse effects of vancomycin that has been prescribed for a patient with acute respiratory distress syndrome (ARDS)? Creatinine Hematocrit Arterial blood gases Liver function tests (LFTs)

Rationale Administration of nephrotoxic drugs such as vancomycin to treat ARDS-related infections can cause renal failure, which would increase blood urea nitrogen and creatinine levels. Although hematocrit will be monitored, anemia is not a common adverse effect of vancomycin. Arterial blood gases will help to determine whether treatment for ARDS is effective but will not be useful in evaluating for adverse effects of vancomycin. LFTs are not affected by vancomycin. p. 1600

Which clinical manifestations of acute respiratory distress syndrome (ARDS) are caused by increased pulmonary capillary permeability during the initial phase of ARDS? Select all that apply. Crackles Tracheal deviation Intercostal retractions Decreasing oxygen saturation Hyperresonance to percussion

Rationale An increase in pulmonary capillary permeability results in fluid movement from the pulmonary capillaries into the interstitial space and alveoli, causing crackles with breathing. Fluid within the alveoli and interstitium also decreases oxygen saturation between the alveoli and pulmonary capillaries, leading to hypoxemia. Interstitial fluid also makes the lungs stiffer and less compliant, increasing the work of breathing and causing labored respirations with intercostal retractions. Tracheal deviation occurs with tension pneumothorax and is not a symptom of ARDS. The lungs have infiltrates with ARDS and will be dull to percussion. pp. 1597-1598

Which medication helps to treat infection in a patient with acute respiratory failure? Propofol Albuterol Fentanyl Azithromycin

Rationale Antibiotics like azithromycin help to prevent infections. Propofol is a sedative and analgesic drug mainly administered to mechanically ventilated patients in respiratory failure. Albuterol is a bronchodilator that reduces bronchospasm and helps to promote alveolar ventilation. Fentanyl is an opioid used to decrease pain and anxiety.

Which action will the nurse take to improve oxygenation in a patient with left-sided pneumonia? Augmented coughing or huff coughing Fluid restriction of less than 2000 mL daily Positioning the patient side-lying on the left side Insertion of a nasogastric tube for enteral feedings

Rationale Augmented coughing and huff coughing techniques may aid the patient in the mobilization of secretions. Since respiratory secretions are usually thick and viscous in pneumonia, fluid intake of at least 2000 to 3000 mL daily is encouraged. A patient with left-sided pneumonia would be positioned on the right side to maximize perfusion to the good lung and improve gas exchange. Nutrition is important in patients with pneumonia, but there is no indication that the patient requires a nasogastric tube for feeding. pp. 1594-1595

When caring for a patient who has pulmonary edema, which finding will the nurse expect when listening to breath sounds? Rhonchi Crackles Bronchial sounds Absent breath sounds

Rationale Because air moving through fluid in the alveoli will make a crackling or popping sound, crackles heard on inspiration may indicate pulmonary edema. Rhonchi are heard when respiratory secretions obstruct larger airways and may be symptomatic of pneumonia or chronic obstructive pulmonary disease (COPD). Bronchial breath sounds heard over the lung periphery indicate consolidation of lung tissue, which often occurs with pneumonia or pleural effusion. Absent or diminished breath sounds may indicate hypoventilation or pneumothorax. p. 1592

In which position will the nurse place the patient with right-sided pneumonia to improve pulmonary gas exchange? Prone position Supine position Tripod position in bed Lying on left side position

Rationale Because pulmonary ventilation and perfusion are improved in dependent areas of the lungs, oxygenation will be maximized when a patient with a right-sided pneumonia is positioned with the good lung down (i.e., lying on left side position). The prone position is sometimes helpful for patients with acute respiratory distress syndrome but is not recommended for patients with a one-sided respiratory infectious process. The supine position makes it difficult for patients to take deep breaths and predisposes to atelectasis. The tripod position helps to increase chest and lung expansion in patients with chronic obstruction pulmonary disease but would not be especially helpful for patients with right-sided pneumonia. p. 1595

Which assessment findings are the earliest indicators of hypoxemic respiratory failure? Select all that apply. Cyanosis Lethargy Agitation Headache Restlessness Confusion

Rationale Because the brain is very sensitive to changes in oxygen level, restlessness, confusion, and agitation are early indications of hypoxemia. Cyanosis is a late sign and does not occur until hypoxemia is severe. Lethargy is a clinical manifestation of hypercapnic respiratory failure and is seen with a high carbon dioxide level. High carbon dioxide levels seen in hypercapnic (ventilatory) respiratory failure also cause headache because of dilation of the blood vessels in the brain and increase in intracranial pressure.

Which process causes hypercapnic respiratory failure in a patient who arrives in the emergency department after an overdose of opioids? Decreased ability to expand the lungs Trapping of carbon dioxide in the airways Damage to the nerve supply to respiratory muscles Depressed central nervous system response to carbon dioxide

Rationale Central nervous system depressants, such as opioids, decrease the carbon dioxide (CO 2) reactivity in the brainstem, leading to decreased respiratory rate and depth. Decreased ability to expand the lungs, such as in a patient with rib fractures, causes hypercapnic respiratory failure due to decreased ability to "blow off" carbon dioxide. Trapping of carbon dioxide in the airways leads to hypercapnic respiratory failure in patients with chronic obstructive pulmonary disease or asthma. Damage to the nerve supply to the diaphragm or intercostal muscles may lead to hypercapnic respiratory failure in patients with cervical spinal cord injury or diseases such as Gillian-Barré syndrome. p. 1591

The nurse is caring for a patient with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation. The nurse monitors for which complications? Select all that apply. Barotrauma Stress ulcers Acute kidney injury Venous thromboembolism (VTE) Ventilator-associated pneumonia Congestive heart failure (CHF)

Rationale Complications of ARDS are many and develop because of the condition itself or its treatment. These complications include barotrauma, stress ulcers, acute kidney injury, venous thromboembolism, and ventilator-associated pneumonia. Barotrauma occurs when alveoli are overdistended during mechanical ventilation. In ARDS, blood is diverted from the gastrointestinal (GI) system to the lungs in an effort to increase body oxygenation, thereby producing stress ulcers. Decreased renal perfusion and decreased oxygen delivery to the kidneys in ARDS often results in acute kidney injury. ARDS puts patients at risk for venous stasis and immobility resulting in venous thromboembolism. Finally, ventilator-associated pneumonia occurs for many reasons, including prolonged mechanical ventilation, impaired host defense, and aspiration of gastric contents. CHF is not a complication associated with mechanical ventilation. p. 1600

Which actions will the nurse take as part of the ventilator bundle when caring for a patient with acute respiratory failure who requires mechanical ventilation? Select all that apply. Elevate head of bed to 30-45 degrees. Keep patient sedated for comfort. Administer proton pump inhibitors. Give injectable anticoagulant medications. Assist with maintaining patient in prone position.

Rationale Components of the ventilator bundle recommended in national guidelines for all patients who are mechanically ventilated include keeping the head of the bed elevated, use of proton pump inhibitors to avoid stress ulcers, and use of anticoagulant medications to avoid venous thromboembolism. Although patients are sometimes sedated for comfort, the ventilator bundle suggests decreasing sedation daily to evaluate readiness for extubation. Although the prone position is sometimes used for patients with acute respiratory distress syndrome (ARDS), it is not part of the ventilator bundle suggested for all ventilated patients. p. 1600

Which actions will the nurse take to prevent ventilator-associated pneumonia (VAP) in a patient with acute respiratory distress syndrome who is on a ventilator? Select all that apply. Administer prescribed anticoagulant. Use chlorhexidine oral rinses daily. Elevate the head of the bed to 90 degrees Conduct a readiness assessment to extubate. Maintain a break from sedation on alternate days.

Rationale Daily oral rinses with chlorhexidine solution and frequent oral care will help to prevent aspiration of oral bacteria that can cause VAP. Since more prolonged mechanical ventilation increases the risk for VAP, the nurse will conduct daily readiness testing to determine whether the patient is ready for extubation. Anticoagulant use prevents venous thromboembolism but does not decrease the risk for VAP. The head of the bed should be elevated 30 to 45 degrees, not 90 degrees. Sedative medications are generally decreased on a daily basis when assessing readiness for extubation. p. 1600

Which change in lung function occurs as a result of loss of surfactant production in a patient with acute respiratory distress syndrome (ARDS)? Bronchoconstriction Loss of alveolar stability Release of inflammatory mediators Change in alveolar-capillary membrane permeability

Rationale Damage to alveolar type I and II cells leads to less surfactant secretion, less alveolar stability, and alveolar collapse (atelectasis). Bronchoconstriction is caused by the release of inflammatory mediators. Inflammatory mediators are released in response to the initial acute lung injury. Changes in alveolar-capillary membrane permeability occur as a result of inflammation at the membrane. p. 1598

Which instruction will the nurse include when teaching a patient how to do huff coughing? "Say the word 'huff' while coughing." "Purse your lips while you are exhaling." "Bend forward and press a pillow into your diaphragm." "Sit with your arms propped on the overbed table or on the knees."

Rationale During huff coughing, the patient says the word "huff" while coughing, which keeps the glottis from closing and improves the effectiveness of the cough. Pursed lip breathing may be used by patients to improve ventilation but is not a coughing technique. During a staged cough, the patient bends forward and presses a pillow into the diaphragm. The tripod position improves ventilation by increasing lung expansion but is not a coughing technique. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options . p. 1595

During which phase of acute respiratory distress syndrome (ARDS) does atelectasis occur due to decreased synthesis of surfactant and inactivation of existing surfactant? Injury Fibrotic Proliferative Refractory hypoxemic

Rationale During the injury phase (exudative phase), atelectasis occurs due to decreased synthesis of surfactant and inactivation of existing surfactant. During the proliferative phase, continued inflammation leads to damage to the pulmonary vasculature, fibrosis, and further decreased compliance. The fibrotic phase is characterized by remodeling of the lung with collagenous and fibrous tissues. Refractory hypoxemia is not a stage of ARDS but is first noticed during the injury (exudative) phase as the patient's hypoxemia continues to worsen despite use of high concentrations of oxygen. pp. 1597-1598

Which pathophysiologic process results in surfactant dysfunction during the injury phase of acute respiratory distress syndrome (ARDS)? Decrease in gas exchange capability Damage to alveolar type I and II cells Engorgement of the peribronchial space Ventilation to perfusion (V/Q) mismatch

Rationale During the injury phase of acute respiratory distress syndrome (ARDS), the alveolar type I and II cells (which produce surfactant) will be damaged. Along with accumulation of fluid and proteins, this cell damage results in surfactant dysfunction. The hyaline membranes that line the alveoli lead to the decrease in gas exchange capability. Engorgement of the peribronchial and perivascular interstitial space results in interstitial edema. Ventilation to perfusion (V/Q) mismatch results in hypoxemia. p. 1598

Which interprofessional actions taken by the nurse will help to prevent development of stress ulcers in a patient with acute respiratory distress syndrome (ARDS)? Select all that apply. Infuse parenteral feeding. Set smaller tidal volumes on the ventilator. Administer prescribed proton pump inhibitors. Insert a nasogastric tube and start enteral feedings. Give fluids as prescribed to prevent hypotension and shock.

Rationale Early initiation of enteral nutrition helps to prevent mucosal damage. Prophylactic management of stress ulcers includes medications that lower gastric acid levels such as proton pump inhibitors. Since shock states divert blood flow from the gut and increase risk for ulcers, management of fluid volume status to avoid hypotension will decrease stress ulcer risk. Parenteral feedings will improve nutritional status but do not provide any decrease in mucosal damage to the gastrointestinal tract. Small tidal volumes are used for patient with ARDS to prevent barotrauma and pneumothorax rather than offering protection against stress ulcers. p. 1600

Before administering prescribed oxygen therapy via face mask, the nurse would assess whether the patient has a history of which problem? Hyperglycemia Claustrophobia Deviated septum Addison's disease

Rationale Face masks may cause anxiety in the patient with claustrophobia, worsening the symptoms of respiratory distress. Hyperglycemia is not a contraindication to or complication of face mask use. Deviated septum may make a nasal cannula uncomfortable but would not affect the use of a face mask. Addison's disease will not affect the use of a face mask, although prescribed corticosteroid dose may be affected by Addison's disease.

In which condition will the nurse expect to hear fine and coarse crackles during lung auscultation? Pneumothorax Pleural effusion Pulmonary edema Asthma exacerbation

Rationale Fine and coarse crackles during auscultation are associated with pulmonary edema and caused by opening of small airways and alveoli during inspiration. With pneumothorax, the nurse would anticipate absent breath sounds over the affected lung. Pleural effusion is also associated with diminished or absent breath sounds. Wheezing (due to airway constriction) or diminished breath sounds (ominous sign) would be heard during an asthma exacerbation.

Which action will the nurse take when caring for a patient with acute respiratory failure due to left-sided pneumonia? Suction the patient every hour. Avoid hyperventilating the patient. Position the patient with the good lung up. Use huff coughing to help to clear secretions.

Rationale Huff coughing helps to clear respiratory secretions from the central airways. Suctioning is indicated only when the patient's condition warrants it (for example, an ineffective cough) and is not scheduled. Hyperventilation may be used before treatments, repositioning, interventions, and so forth to allow the patient to have a reserve of oxygen prior to stressful activities. Positioning for optimal oxygenation and ventilation is good lung down, not up.

Which action will the nurse take when a patient is receiving methylprednisolone IV? Obtain apical pulse rate. Assess for hypoglycemia. Observe for increased lethargy. Monitor serum potassium levels.

Rationale Hypokalemia is a possible side effect of corticosteroid use, and the nurse will monitor potassium levels when patients receive medications such as methylprednisolone. Heart rate and rhythm are not directly affected by corticosteroids. Corticosteroids may increase blood glucose, but hypoglycemia is not an adverse effect of methylprednisolone. Increased lethargy is not an expected adverse effect of corticosteroid use. p. 1596

Which clinical manifestations of respiratory failure are associated with hypoxemia? Select all that apply. Fatigue Confusion Restlessness Muscle weakness Morning headache

Rationale Hypoxemia refers to decrease in arterial oxygen and may manifest as fatigue, confusion, and restlessness because of inadequate oxygen delivery to the brain. Muscle weakness is associated with hypercapnic respiratory failure because of elevated partial pressure of carbon dioxide in arterial blood (PaCO 2) and carbonic acid. Morning headaches are a symptom of hypercapnic respiratory failure, as elevated PaCO 2 levels cause cerebral vasodilation and mild intracranial pressure increases. p. 1591

Which process causes hypoxemic respiratory failure? Inability to remove sufficient carbon dioxide Imbalance between ventilatory supply and demand Inability to increase lung ventilation in response to metabolic demands Inadequate oxygen transfer between the alveoli and the pulmonary capillaries

Rationale Hypoxemic respiratory failure occurs due to inadequate oxygen transfer between the alveoli and the pulmonary capillaries. The patient experiences hypercapnic respiratory failure because of the inability to remove sufficient carbon dioxide to maintain a normal partial pressure of carbon dioxide in arterial blood (PaCO 2). An imbalance between ventilatory supply and demand increases PaCO 2 and leads to hypercapnia. An inability to increase ventilation in response to metabolic demands also causes hypercapnia and hypercapnic respiratory failure. p. 1588

Which conditions predispose a patient to acute respiratory distress syndrome (ARDS) by causing an indirect lung injury? Select all that apply. Sepsis Bacterial pneumonia Opioid drug overdose Severe massive trauma Aspiration of gastric contents

Rationale In indirect lung injury, a problem outside the lung leads to widespread inflammation, which affects the lung as well as other organs. Sepsis caused by gram-negative bacteria can predispose patients to the development of ARDS with an indirect lung injury. Excessive use of opioid drugs can indirectly lead to ARDS. Indirect injury to the lung by a severe massive trauma caused by a head injury can also lead to ARDS. In direct lung injury, pathogens come into direct contact with the lungs as occurs with pneumonia. Aspiration of gastric contents also causes direct lung injury as gastric contents come into contact with lung tissues. p. 1597

The nurse provides care for a patient who is in the early phases of acute respiratory distress syndrome (ARDS). The nurse identifies that the patient is placed in the prone position for which primary reason? To reexpand alveoli To consolidate secretions To deliver oxygen to the blood To allow for effective chest physiotherapy

Rationale In the early phases of ARDS, fluid moves freely throughout the lung. Because of gravity, fluid pools in dependent regions of the lung. As a result, some alveoli are fluid filled (dependent areas) while others are air filled (nondependent areas). When the patient is supine, the heart and mediastinal contents place added pressure on the lungs. Consequently, the supine position predisposes all patients, including those with ARDS, to atelectasis; thus, the patient should be placed in the prone position to reexpand alveoli. Secretions are mobilized and can be suctioned out. Delivering oxygen into the blood is the purpose of extracorporeal membrane oxygenation (ECMO). Continual lateral rotation therapy (CLRT) can provide the means for administering chest physiotherapy. p. 1601

Which statement best describes intrapulmonary shunt? Decrease in arterial partial pressure of oxygen (PaO 2) occurs. Carbon dioxide levels increase because of poor ventilation. Blood flows through the lungs without taking part in gas exchange. Cardiac defects lead to abnormal blood flow through the heart and lungs.

Rationale Intrapulmonary shunting occurs when blood flows through the pulmonary capillary system but does not take part in gas exchange. This occurs when the alveoli are filled with fluid, such as in pneumonia or pulmonary edema. Although a decrease in PaO 2 is common with intrapulmonary shunting, there are many other causes of low PaO 2. Carbon dioxide levels may increase with intrapulmonary shunting but are more likely to increase with poor ventilation such as in patients with chronic obstructive pulmonary disease. Cardiac defects such as ventricular-septal defect cause shunting of blood from the right to the left side of the heart, but this is anatomic shunt rather than intrapulmonary shunting. p. 1590

Which benefits does noninvasive positive pressure ventilation (NIPPV) have over other artificial airways? Select all that apply. It improves respiratory drive. It helps patients manage excessive secretions. It reduces the need for rapidly acting bronchodilator therapy. It provides ventilatory support without endotracheal intubation. It decreases the need for intubation in patients who are spontaneously breathing.

Rationale NIPPV provides positive pressure ventilation without the need for endotracheal intubation and decreases the need for intubation in patients who are spontaneously breathing. Respiratory drive is not affected by NIPPV, and patients need to have adequate spontaneous respiratory rate to use this treatment. NIPPV traps secretions in the mask and is not appropriate for patients who have a lot of respiratory secretions. Patients who receive NIPPV may still need to receive bronchodilator therapy because NIPPV does not decrease airway spasm or narrowing.

After observing a patient whose chest and abdomen move inward during inspiration, how will the nurse document this finding? Intercostal retractions Three-word dyspnea Pursed-lip breathing Paradoxical breathing

Rationale Normally, the thorax and abdomen move outward on inspiration and inward on exhalation. During paradoxical breathing, the abdomen and chest move inward during inspiration due to maximal use of the accessory muscles of respiration. Intercostal retractions are an abnormal finding during inspiration and signify increased work of breathing and use of accessory muscles to assist in breathing. Three-word dyspnea means that the patient can only say three words before another breath is needed. Pursed-lip breathing occurs during the expiratory cycle and is used to exhale more completely and avoid air trapping. STUDY TIP: Identify your problem areas that need attention. Do not waste time on restudying information you know. p. 1592

Which respiratory complications will the nurse assess for when caring for a patient with acute respiratory distress syndrome who requires mechanical ventilation with positive end- expiratory pressure (PEEP)? Select all that apply. Barotrauma Pneumothorax Pulmonary hemorrhage Decreased cardiac output Ventilator-associated pneumonia

Rationale Positive pressure ventilation (PPV), especially with PEEP, can overdistend alveoli and cause barotrauma, alveolar rupture, and pneumothorax. Cardiac output can decrease as the increased intrathoracic pressure leads to decreased venous return and preload reduction. Ventilator-associated pneumonia is a possible complication as endotracheal intubation or tracheostomy increases aspiration risk. Pulmonary hemorrhage is not a common complication since the pulmonary capillaries are not damaged by PPV or PEEP.

Which position is used to decrease atelectasis and improve refractory hypoxemia in patients with acute respiratory distress syndrome (ARDS)? Prone position Tripod position Supine position Lateral position

Rationale Prone positioning helps to recruit alveoli in the posterior part of the lung, which are compressed by the heart and mediastinal structures in the supine position. In addition, prone positioning improves blood flow to the better ventilated anterior alveoli, improving ventilation-perfusion mismatch. It is used in severe ARDS for patients with refractory hypoxemia that has not responded to other actions. The tripod position is helpful for patients with chronic obstructive lung disease to help to expand the lung but would not be used on a patient receiving mechanical ventilation. The supine position increases atelectasis in the posterior chest and will not be helpful to a patient with refractory hypoxemia. Lateral positioning may help to move respiratory secretions into large airways and improve perfusion to better ventilated parts of the lung in patients with diseases such as one-sided pneumonia but will not be used to improve refractory hypoxemia in ARDS, which affects all sections of the lung.

Which patient information is obtained through the use of pulse oximetry? Arterial oxygen saturation (SpO 2) Venous oxygen saturation (SvO 2) Partial pressure of arterial oxygen (PaO 2) Partial pressure of arterial carbon dioxide (PaCO 2)

Rationale Pulse oximetry is a noninvasive method to determine arterial oxygen saturation. SvO 2 is obtained through sampling of venous blood, not through pulse oximetry. The PaO 2 is determined through arterial blood gas analysis. The PaCO 2 is obtained through arterial blood gases analysis. p. 1588

Which condition is an example of an indirect lung injury that increases the risk for developing acute respiratory distress syndrome (ARDS)? Near drowning Aspiration Pneumonia Severe trauma

Rationale Severe trauma results in inflammation, which can cause indirect injury to the lungs and increase the risk for developing ARDS. Near drowning causes a direct injury to the lung. Aspiration also results in direct lung injury. Pneumonia is a direct injury to the lung. p. 1597

Which action will the nurse take first for a patient who has new onset confusion and agitation? Check oxygen saturation. Start oxygen via nasal cannula. Activate the Rapid Response Team. Administer the prescribed PRN midazolam.

Rationale Since hypoxemia affects the central nervous system very quickly, confusion and agitation are frequently the initial manifestations of hypoxemia. The nurse's first action will be to check the patient's oxygen saturation. Oxygen administration may be initiated if the oxygen saturation is low. The Rapid Response Team may be notified about the changes in the patient condition, but assessment of oxygen saturation and other parameters is needed first. Benzodiazepines such as midazolam may be appropriate for agitation, but further assessment of patient status is needed first.

Which finding by the nurse is the best indicator that measures to improve oxygenation in a patient on mechanical ventilation for acute respiratory distress syndrome have been effective? Oxygen saturation 90% to 93% Decreased rhonchi and crackles Patient report of improving dyspnea Stable heart rate and BP

Rationale Since oxygen saturations of 90% to 93% are in the low normal range, this is the best indicator that treatment has improved oxygen saturation. Clearing lung sounds may also indicate improvement, but oxygen saturation is a better indicator for improvement in oxygenation. Patient report of improvement in dyspnea is also an indicator of effective treatment, but oxygen saturation in the normal range is a clearer indicator. Heart rate and BP stabilization also occurs with improvement in respiratory status but is not as clear an indicator of improvement in oxygenation as oxygen saturation. pp. 1600-1601

Which diagnostic test result will the nurse expect when a patient has respiratory failure as a result of a pulmonary embolism? Congestion on chest x-ray Increased PaO 2 on arterial blood gases Gram-positive organisms in the sputum specimen Ventilation-perfusion (V/Q) mismatch on lung scan

Rationale Since pulmonary emboli will obstruct blood flow through the pulmonary capillaries, a mismatch between pulmonary perfusion and ventilation will occur and lead to hypoxemia. Pulmonary emboli do not cause alveolar congestion, and a chest x-ray will not show pulmonary congestion. PaO 2 will decrease with a pulmonary embolism because gas exchange will not occur in those alveoli where the pulmonary capillaries are obstructed by pulmonary emboli. Pulmonary embolism is not an infectious process, and sputum specimens will be negative for bacteria. pp. 1589-1590

Which action will the nurse take to help a patient to perform staged coughing? Position with the good lung down during coughing efforts. Push upward from the base of the lungs as the patient coughs Assist the patient to push a pillow against the diaphragm while coughing. Have the patient place the arms propped on an overbed table when coughing.

Rationale Staged coughing is performed while bending forward with a pillow pressed against the diaphragm. Positioning with the good lung down prior to coughing may help mobilize secretions, but staged coughing is performed with the patient upright. Pushing upward from the base of the lungs is done when assisting the patient with augmented or "quad" coughing. The tripod position is helpful in expanding the lungs, but staged coughing requires the use of the patient's arms and hands to augment diaphragmatic contraction when coughing. p. 1595

Which information will the nurse obtain when collecting subjective data about a patient with respiratory failure? Vital signs Health history Neurologic findings Diagnostic test results

Rationale Subjective data include information that the patient provides, such as past health history, medications, surgeries, or other treatments. Vital signs are objective findings obtained by the nurse as part of the physical assessment. Neurologic findings are objective data obtained during the physical assessment. Diagnostic testing provides objective information.

When a patient who has been successfully treated for acute respiratory distress syndrome (ARDS) reports anxiety and vivid dreams that interfere with sleep, which action will the nurse take? Check oxygen saturation. Refer the patient for counselling. Recommend changes in diet and exercise. Assess orientation to person, place, and time.

Rationale Survivors of ARDS may have anxiety, depression, poor memory, and posttraumatic stress disorder as long- term complications, and counselling is helpful in identifying and addressing these mental health issues. Since the patient has recovered from ARDS, assessment of oxygen saturation is not needed. There is no data indicating that the patient has diet or exercise habits that are contributing to the symptoms. Since the patient data do not indicate delirium or disorientation, assessment of orientation is not necessary. Test-Taking Tip: Look for answers that focus on the patient or are directed toward psychologic change. p. 1600

Which diagnostic finding for a patient is most important to report to the health care provider? Ventilation/perfusion ratio is 1:1. Inspiratory to expiratory ratio is 1:2. Partial pressure of oxygen in arterial blood (PaO 2) is 50 mm Hg. Partial pressure of carbon dioxide in arterial blood (PaCO 2) is 35 mm Hg.

Rationale The PaO2 of 50 mm Hg indicates a need for rapid actions such as oxygen administration and diagnostic testing for causes of hypoxemia. A ventilation/perfusion ratio of 1:1 is a normal finding and does not need to be immediately reported. An inspiratory to expiratory ratio of 1:2 is a normal finding, and there is no need for any change in treatment. A PaCO 2 of 35 mm Hg is in the normal range and does not need to be reported quickly to the health care provider.

Which pathophysiologic processes occur during the fibrotic phase of acute respiratory distress syndrome (ARDS)? Select all that apply. Remodeled lung Deceased lung compliance Impairment of gas exchange Development of pulmonary edema Formation of hyaline membranes

Rationale The fibrotic phase, also known as the chronic or late phase of ARDS, occurs two to three weeks post-lung injury. The lung is completely remodeled by this time with dense and fibrous tissues. The scarring and fibrosis result in the decrease of lung compliance. Impairment in gas exchange is significant because the interstitium is fibrotic in nature. Pulmonary edema occurs in the initial exudative phase of ARDS as the alveolar-pulmonary capillary membrane permeability increases and fluid leaks into the alveoli. Formation of hyaline membranes also occurs in the exudative phase as necrotic cells, proteins, and fibrin line the alveoli, forming membranes that slow gas exchange.

After reviewing a patient's assessment findings, the nurse suspects a diagnosis of acute respiratory distress syndrome (ARDS). Which phase of ARDS is the patient experiencing? Injury phase Reparative phase Proliferative phase Fibroproliferative phase

Rationale The injury, or exudative phase, is the first phase in the progression of ARDS. This phase usually occurs 24 to 72 hours after the lung insult or injury and lasts seven days. It is characterized by mild respiratory symptoms (dyspnea, tachypnea, cough, and restlessness). Lung auscultation shows normal lungs or fine scattered crackles. The arterial blood gases (ABGs) show mild hypoxemia and respiratory alkalosis due to hyperventilation. The chest x-ray is usually normal. In the reparative phase (also known as the proliferative phase), signs and symptoms worsen. The chest x-ray begins to show diffuse bilateral infiltrates. In the fibroproliferative phase, scarring of the lungs occurs, and lung compliance is decreased. p. 1597

Which instruction will the nurse give a patient with chronic obstructive pulmonary disease (COPD) who shows increased work of breathing (WOB)? "Lie in the prone position." "Avoid the side-lying position." "Sit with your arms propped on the overbed table." "Lie down with your hands clasped over the belly."

Rationale The tripod position will increase the anterior-posterior chest diameter and make it easier to expand the chest, decreasing the WOB and improving gas exchange. Prone positioning is sometimes used for patients with acute respiratory distress syndrome who are receiving mechanical ventilation but would restrict movement of the chest and increase WOB for this patient. The side-lying position can improve oxygenation in a patient with pneumonia on one side, who may be positioned with the good lung down. WOB is usually increased when patients lie down since it is harder to fully expand the chest while lying. pp. 1592, 1594

The nurse provides care for a patient with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation. After reviewing the patient's medical record, the nurse determines that which assessment is the most important? Anxiety level Cardiac output Peripheral pulses Presence of abdominal rigidity

Rationale Twenty cm of positive end-expiratory pressure (PEEP) is considered to be a high level. As the PEEP level increases, the venous return to the heart, and BP and cardiac output (CO) decrease. As the CO decreases, perfusion to vital organs also decreases, causing damage to vital organs and the brain. It is most important for the nurse to assess the patient's cardiac output because dangerous drops can occur with high levels of PEEP. Assessing for anxiety, assessing the patient's peripheral pulses, and evaluating if abdominal rigidity is present should also be performed, but the priority is assessing cardiac output. p. 1600

Which actions will the nurse take to help to prevent stress ulcers in a patient with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation? Select all that apply. Elevate the head of the bed. Provide frequent oral hygiene. Infuse prescribed pantoprazole. Administer prescribed enteral feedings. Give prescribed anticoagulant injections.

Rationale Use of proton pump inhibitors such as pantoprazole and administration of enteral feedings will help to protect the gastric mucosa and prevent stress ulcers. Elevation of the head of the bed and frequent oral hygiene are needed but are implemented to prevent ventilator-associated pneumonia. Anticoagulants are frequently used in patients with ARDS to prevent venous thromboembolism but would not prevent stress ulcers. p. 1600

A patient with acute respiratory distress syndrome (ARDS) on mechanical ventilation is receiving vecuronium by continuous IV infusion. The nurse anticipates that which other types of medications will be prescribed? A sedative and a diuretic An analgesic and sedative An antibiotic and analgesic A diuretic and an antibiotic

Rationale Vecuronium, a neuromuscular blocking agent (NMBA) that relaxes skeletal muscles, is used in the treatment of ARDS when patients are asynchronous with mechanical ventilation. Under the influence of an NMBA, the patient is awake and can feel pain but is unable to move. Because this can be very frightening for the patient, analgesics and sedatives must also be prescribed. Because ARDS is caused by an inflammatory process, diuretics and antibiotics are not normally used. p. 1602

Which complication can occur when a patient with acute respiratory distress syndrome (ARDS) is receiving mechanical ventilation with positive end-expiratory pressure (PEEP) or high tidal volumes? Volutrauma Aspiration Stress ulcers Hypercapnia

Rationale Volutrauma can occur with the use of PEEP or when large tidal volumes are delivered to noncompliant lungs (as occurs in ARDS). Aspiration is a possible complication of intubation and mechanical ventilation but is not caused by high tidal volumes. Stress ulcers may occur in ARDS because blood flow is diverted from the gastrointestinal tract, leading to ischemia, but stress ulcers are not caused by large tidal volumes. Large tidal volumes would be likely to lower carbon dioxide levels rather than cause hypercapnia. p. 1601

Which actions help to prevent the development of volutrauma in a patient receiving positive pressure mechanical ventilation? Select all that apply. Sterile techniques Strict hand washing Smaller tidal volumes Pressure-control ventilation Mouth care and oral hygiene

Rationale Volutrauma occurs when large tidal volumes are given to a mechanically ventilated patient and can be prevented by giving smaller tidal volumes or using pressure-control ventilation. Sterile technique is used during endotracheal suctioning to prevent ventilator-associated pneumonia (VAP). Strict hand washing is helpful in prevention of infectious complications such as VAP. Oral hygiene is used to prevent VAP. p. 1601