NUR250 Final Group 3 - ARDS - NCLEX questions

5. The nurse caring for a client with an acute lung injury understands ARDS is acute respiratory failure with these features: Select all that apply. a. Reduced surfactant activity b. Bradycardia and decreased respiratory rate c. Hypoxemia that persists even after 100% oxygen treatment d. Bilateral pulmonary edema e. Inflammation with formation of Aschoff bodies f. Dense pulmonary infiltrates on x-ray (ground glass appearance)

Answer: A, C, D, F Reduced surfactant activity causes decreased pulmonary compliance, a feature of ARDS. ARDS is associated with tachycardia and an increase in respiratory rate with intercostal retractions. Refractory hypoxemia is a cardinal feature of ARDS, along with pulmonary edema and "whited-out" appearance on x-ray. Inflammation associated with Aschoff bodies are features of Rheumatic carditis.

3. The nurse is evaluating the client's response to treatment of a pleural effusion with a chest tube. The nurse notes a respiratory rate of 20 breaths per minute, fluctuation of the fluid level in the water seal chamber, and a decrease in the amount of drainage by 30 mL since the previous shift. Based on this information, which interpretation should the nurse make? a. Water should be added to the water seal chamber b. The client is responding well to treatment c. Suction should be decreased to the system d. The system should be assessed for an air leak

Answer: B Fluctuations in the water seal chamber is an expected and normal finding with a chest tube. Since the client is being treated for a pleural effusion, it can eb determined that they are responding well to treatment if the amount of drainage is gradually decreasing because drainage is being effectively removed. If drainage were to stop suddenly, the chest tube should be assessed for a kink or blockage. There is no indication to decrease suction, in fact it is unclear whether the client is hooked to suction at all. There is no data to indicate an air leak or need to add water to the water seal chamber.

9. The nurse is caring for a client who is on a mechanical ventilator. Blood gas results indicate a pH of 7.50 and a PaCO2 of 30mmHg. The nurse has determined that the client is experiencing respiratory alkalosis. Which laboratory value would most likely be noted in this condition? a. Sodium level of 145 mEq/L b. Potassium level of 3.0 mEq/L c. Magnesium level of 1.3 mEq/L d. Phosphorus level of 4.3 mg/dL

Answer: B Hypokalemia - Respiratory alkalosis is defined as a deficit of carbonic acid or a decrease in hydrogen ion concentration that results from the accumulation of base or from a loss of acid without a comparable loss of base in the body fluids. This occurs in conditions that cause overstimulation of the respiratory system. Clinical manifestations of respiratory alkalosis include lethargy, lightheadedness, confusion, tachycardia, dysrhythmias related to hypokalemia, nausea, vomiting, epigastric pain, and numbness and tingling of the extremities. All three incorrect options identify normal laboratory values. The correct option identifies the presence of hypokalemia.

10. The nurse has a prescription to give a client salmeterol, 2 puffs, and beclomethasone dipropionate, 2 puffs, by metered-dose inhaler. The nurse should administer the medication using which procedure? a. Beclomethasone first and then salmeterol b. Salmeterol first and then the beclomethasone c. Alternating a single puff of each, beginning with the salmeterol d. Alternating a single puff of each, beginning with the beclomethasone

Answer: B Salmeterol is an adrenergic bronchodilator and beclomethasone is a glucocorticoid. Bronchodilators are always administered before glucocorticoids when both are to be given on the same time schedule. This allows for the widening of the air passages by the bronchodilator, which then makes the glucocorticoid more effective.

4. The nurse is trouble-shooting multiple ventilator alarms sounding for a client who is intubated and being mechanically ventilated. The alarms persist despite suctioning, repositioning the client and ensuring that the ventilator tubing is unobstructed. Which actions will the nurse perform next? Select all that apply. a. Turn off all ventilator alarms until a cause is found to prevent scaring the patient. b. Page the HCP to request additional sedation. c. Ensure that the endotracheal tube marking is at the client's incisor d. Increase the PEEP to improve gas exchange e. Disconnect the client from the ventilator and use the manual resuscitation bag f. Change all ventilator tubing g. STAT page the respiratory therapist. h. Determine when the client received the last dose of the paralytic agent.

Answer: B, C, E, F

8. A male patient's X-ray result reveals bilateral white-outs, indicating adult respiratory distress syndrome (ARDS). This syndrome results from: a. Cardiogenic pulmonary edema b. Respiratory alkalosis c. Increased pulmonary capillary permeability d. Renal failure

Answer: C ARDS results from increased pulmonary capillary permeability, which leads to noncardiogenic pulmonary edema. In cardiogenic pulmonary edema, pulmonary congestion occurs secondary to heart failure. In the initial stage of ARDS, respiratory alkalosis may arise secondary to hyperventilation; however, it does not cause ARDS. Renal failure does not cause ARDS, either.

2. The low-pressure alarm sounds on a ventilator. The nurse assesses and then attempts to determine the cause of the alarm. If unsuccessful in determining the cause of the alarm, the nurse should take what initial action? a. Administer oxygen b. Check the client's vital signs c. Ventilate the client manually d. Start cardiopulmonary resuscitation

Answer: C If at any time an alarm is sounding, and the nurse cannot quickly ascertain the problem, the client is disconnected from the ventilator and manual resuscitation is used to support respirations until the problem can be corrected. No reason is given to begin CPR. Checking vital signs is not the initial action. Although O2 is helpful, it will not provide ventilation to the client.

18. The low tidal volume alarm on a client's ventilator keeps sounding. What is the nurse's first action? A. Manually ventilate the client. B. Put air into the endotracheal tube cuff. C. Check ventilator connections. D. Call the physician.

Answer: C Rationale: Check ventilator connections Rationale: Ventilator connections should be check initially and loose connections or disconnections should be fixed. If there is no immediate problem found, the client should be manually ventilated and another person should check the ventilator connections.

6. A male adult patient on mechanical ventilation is receiving pancuronium bromide (Pavulon), 0.01 mg/kg I.V. as needed. Which assessment finding indicates that the patient needs another pancuronium dose? a. Leg movement b. Finger movement c. Lip movement d. Fighting the ventilator

Answer: D Pancuronium, a nondepolarizing blocking agent, is used for muscle relaxation and paralysis. It assists mechanical ventilation by promoting encdotracheal intubation and paralyzing the patient so that the mechanical ventilator can do its work. Fighting the ventilator is a sign that the patient needs another pancuronium dose. The nurse should administer 0.01 to 0.02 mg/kg I.V. every 20 to 60 minutes. Movement of the legs, or lips has no effect on the ventilator and therefore is not used to determine the need for another dose.

1. The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome? a. Bilateral Wheezing b. Inspiratory crackles c. Intercostal retractions d. Increased respiratory rate

Answer: D Rationale: The earliest detectable sign of ARDS is an increased RR, which can begin from 1-96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles.

7. Nurse Ruth assessing a patient for tracheal displacement should know that the trachea will deviate toward the: a. Contralateral side in a simple pneumothorax b. Affected side in a hemothorax c. Affected side in a tension pneumothorax d. Contralateral side in hemothorax

Answer: D The trachea will shift according to the pressure gradients within the thoracic cavity. In tension pneumothorax and hemothorax, accumulation of air or fluid causes a shift away from the injured side. If there is no significant air or fluid accumulation, the trachea will not shift. Tracheal deviation toward the contralateral side in simple pneumothorax is seen when the thoracic contents shift in response to the release of normal thoracic pressure gradients on the injured side.

16. The client is on CPAP for weaning from a mechanical ventilator. Assessment reveals a respiratory rate of 32/min, oxygen saturation of 88 percent, and use of accessory muscles. What should the nurse anticipate will occur? A. The FiO2 will be increased. B. Weaning will continue. C. The client will be placed back on full ventilatory support. D. The client will be extubated.

C. Rationale: Weaning should be discontinued, as the client is showing signs of intolerance

17. Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the family members of a client with ARDS is correct? A. "PEEP will prevent fibrosis of the lung from occurring." B. "PEEP will push more air into the lungs during inhalation." C. "PEEP allows the ventilator to deliver 100% oxygen to the lungs." D. "PEEP prevents the lung air sacs from collapsing during exhalation."

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

12. You're providing discharge teaching to a client who was admitted for pneumonia. You are discussing measures the client can take to prevent pneumonia. Which of the following statements by the client indicates they did NOT understand your education material? A. "I'll use hand sanitizer regularly while I'm out in public." B. "It is important I don't receive the Pneumovax vaccine since I'm already immune to pneumonia." C. "I will try to avoid large crowds of people during the peak of flu season." D. "It is important I try to quit smoking."

The answer is B. Rationale: All the other options are correct statements regarding the prevention of pneumonia. However, option B is incorrect because although the patient has had pneumonia they should still receive the Pneumovax vaccine to prevent other forms of pneumonia.

15. A client is on mechanical ventilation with PEEP (positive end-expiratory pressure). Which finding below indicates the client is developing a complication related to their therapy and requires immediate treatment? A. HCO3 26 mmHg B. Blood pressure 70/45 C. PaO2 80 mmHg D. PaCO2 38 mmHg

The answer is B. Rationale: Mechanical ventilation with PEEP can cause issues with intrathoracic pressure and decrease the cardiac output (watch out for a low blood pressure) along with hyperinflation of the lungs (possible pneumothorax or subq emphysema which is air that escapes into the skin because the lungs are leaking air).

20. You're providing care to a patient who is being treated for aspiration pneumonia. The patient is on a 100% non-rebreather mask. Which finding below is a HALLMARK sign and symptom that the patient is developing acute respiratory distress syndrome (ARDS)? A. The patient is experiencing bradypnea. B. The patient is tired and confused. C. The patient's PaO2 remains at 45 mmHg. D. The patient's blood pressure is 180/96.

The answer is C. Rationale: A hallmark sign and symptom found in ARDS is refractory hypoxemia. This is where that although the patient is receiving a high amount of oxygen (here a 100% non-rebreather mask) the patient is STILL hypoxic. Option C is the answer because it states the patient's arterial oxygen level is remaining at 45 mmHg (a normal is 80 mmHg but when treating patients with ARDS a goal is at least 60 mmHg). Yes, the patient can be tired and confused from a low oxygen level BUT this question wants to know the HALLMARK sign and symp

14. A client has been hospitalized in the ICU for a near drowning event. The client's respiratory function has been deteriorating over the last 24 hours. The physician suspects acute respiratory distress syndrome. A STAT chest x-ray is ordered. What finding on the chest x-ray is indicative of ARDS? A. infiltrates only on the upper lobes B. enlargement of the heart with bilateral lower lobe infiltrates C. white-out infiltrates bilaterally D. normal chest x-ray

The answer is C. Rationale: This is a finding found in ARDS....pronounce white-out infiltrates bilaterally.

11. Which of the following patients are MOST at risk for developing pneumonia? Select-all-that-apply: A. A 53-year-old female recovering from abdominal surgery. B. A 69-year-old patient who recently received the pneumococcal conjugate vaccine. C. A 42-year-old male with COPD and is on continuous oxygen via nasal cannula. D. A 8 month old with RSV (respiratory syncytial virus) infection.

The answers are A, C, and D. Rationale: Risks factors for pneumonia include: recent surgery, lung disorder (ex: COPD), and viral infection (ex: RSV). Option B is a preventive measure in preventing pneumonia.

13. Which of the following are typical signs and symptoms of pneumonia? Select-all-that-apply: A. Stridor B. Coarse crackles C. Oxygen saturation less than 90% D. Non-productive, nagging cough E. Elevated white blood cells F. Low PCO2 of less than 35 G. Tachypnea

The answers are B, C, E, and G. Rationale: These are typical signs and symptoms of pneumonia. Stridor is not very common. A PRODUCTIVE cough that can be nagging is very typical, and there is usually a HIGH PCO2 of 45 or greater due to the lungs retaining carbon dioxide.

19. As the nurse you know that acute respiratory distress syndrome (ARDS) can be caused by direct or indirect lung injury. Select below all the INDIRECT causes of ARDS: A. Drowning B. Aspiration C. Sepsis D. Blood transfusion E. Pneumonia F. Pancreatitis

The answers are: C, D, F Rationale: Indirect causes are processes that can cause inflammation OUTSIDE of the lungs....so the issue arises somewhere outside the lungs. Therefore, sepsis (infection...as long as it is outside the lungs), blood transfusion, and pancreatitis are INDIRECT causes. Drowning, aspiration, and pneumonia are issues that arise in the lungs (therefore, they are DIRECT causes of lung injury).