Respiratory Failure and Acute Respiratory Distress Syndrome

Common causes of ARDS

Sepsis, trauma, aspiration, pneumonia, embolism, toxins inhaled, drowning, shock, opioid drug overdose

ARDS dianostic

PaO2/FIO2 <200, Chest x-ray show bilateral interstitial and alveolar infiltrates, PAWP <18mmHg, rule out Heart failure

ARDS manifestation

- Increased respiratory discomfort - Increased WOB evident - Decreased lung compliance, volumes, and functional residual capacity - Diaphoresis - Decreased mentation - Cyanosis - Pallor - Scattered to diffuse crackles and rhonchi - Diffuse bilateral infiltrates - Refractory hypoxemia - Hypercapnia once respiratory muscles fatigue

Which of the following is the best reason for inspecting the oral cavity during a complete pulmonary assessment? 1. Can provide evidence of hypoxia 2. Can provide evidence of hypercapnia 3. Can provide evidence of dehydration 4. Can provide evidence of nutritional status

1 (Severe hypoxia will be manifested by central cyanosis, which is evident in the oral and circumoral areas. Although dehydration and nutritional status can both be partially assessed by oral cavity inspection, that information is not as vital as determining hypoxia.)

ARDS exudative phase

1-7 days, increase permeability cause interstitial edema, intrapulmonary shunt develops leas to atelectasis and refractory hypoxemia

ARDS fibrotic phase

14-21 days, lung remodeled by collagenous and fibrous tissues

A postoperative patient has a respiratory rate of 10 breaths/min with an SpO2 of 95%. Arterial blood gas (ABG) values are PaO2 85, pH 7.32, PaCO2 51, and HCO3 24. The patient is experiencing: 1. respiratory alkalosis. 2. respiratory acidosis. 3. metabolic alkalosis. 4. metabolic acidosis.

2 (The patient is experiencing respiratory acidosis as evidenced by a pH below 7.35, a PaCO2 above 35, and a normal HCO3. Respiratory alkalosis would have a pH above 7.45, a PaCO2 below 35, and a normal HCO3. Metabolic alkalosis would have a pH above 7.45, an HCO3 above 26, and a normal PaCO2. Metabolic acidosis would have a pH below 7.35, an HCO3 below 22, and a normal PaCO2.)

Mr. J. is admitted to the critical care unit with acute respiratory failure secondary to COPD. He has a 15-year history of emphysema and bronchitis. On inspection you note that he is air trapping. While auscultating his chest, you note the presence of coarse, rumbling, low-pitched sounds in the right middle and lower lobes. On further inspection of Mr. J. you notice that his fingers appear discolored. This is a result of: 1. clubbing. 2. central cyanosis. 3. peripheral cyanosis. 4. chronic tuberculosis.

3 (Discoloration of the fingers is an indication of peripheral cyanosis.)

Which ABG is considered compensated? 1. pH 7.22, PaCO255, HCO325 2. pH 7.33, PaCO2 62, HCO335 3. pH 7.35, PaCO2 48, HCO328 4. pH 7.50, PaCO2 42, HCO333

3 (The ABG of pH 7.35, PaCO2 of 48, and HCO3 of 28 is a compensated respiratory acidosis. The pH has come back within normal range as a result of the retaining HCO3 to buffer for the excess PaCO2. The ABG of pH 7.22, PaCO2 of 55, and HCO3 of 25 is an uncompensated respiratory acidosis. The ABG of pH 7.33, PaCO2 of 62, and HCO3 of 35 is a partially compensated respiratory acidosis. The ABG of pH 7.50, PaCO2 of 42, and HCO3 of 33 is an uncompensated metabolic alkalosis.)

Which of the following best describes how scoliosis interferes with respiratory function? 1. Decreased lung tissue elasticity 2. Increased air trapping 3. Decreased lung expansion 4. Paralysis of the diaphragm

3 (The abnormal forward curvature of the spine decreases lung expansion. It does not cause the changes presented in the other choices.)

A patient presents with chest trauma, complaints of dyspnea, shortness of breath, tachypnea, and tracheal deviation to the right. In addition, the patient's tongue is blue gray. Which of the following assessment data would be most consistent with this presentation? 1. PaO2 88; PCO2 55 2. Absent breath sounds in all right lung fields 3. Absent breath sounds in all left lung fields 4. Diminished breath sounds in all fields

3 (The clinical picture described is most consistent with left pneumothorax. This would cause the trachea to deviate to the right, away from the increasing pressure of the left. A pneumothorax this severe would completely collapse the right lung thus causing absent breath sounds in that lung.)

On assessment of a patient you note fremitus over the trachea but not in the lung periphery. You know that this most likely represents: 1. bilateral pleural effusion. 2. bronchial obstruction. 3. a normal finding. 4. apical pneumothorax.

3 (This describes the normal findings for fremitus. Fremitus, if noted in the periphery, can be caused by the other findings.)

Which of the following is an example of a disorder with increased tactile fremitus? 1. Emphysema 2. Atelectasis 3. Pneumothorax 4. Pneumonia

4 (Examples of disorders that increase tactile fremitus include pneumonia, lung cancer, and pulmonary fibrosis.)

ARDS reparative phase

7-14days, lung tissue becomes dense and fibrous, lung compliance decrease

27. A patient's assessment data present as follows: pH, 7.10; PaCO2, 60 mm Hg; PaO2, 40 mm Hg; HCO3, 24 mEq/L; RR, 34 breaths/min; HR, 128 beats/min; and BP, 180/92 mm Hg. This condition is best described as a. uncompensated respiratory acidosis. b. uncompensated metabolic acidosis. c. compensated metabolic acidosis. d. compensated respiratory acidosis.

ANS: A The pH is below normal range (7.35-7.45), so this is uncompensated acidosis. The PaCO2 is markedly elevated, and the HCO3 is normal. This indicates uncompensated respiratory acidosis. Uncompensated respiratory acidosis values include a pH below 7.35, PACO2 above 45 mm Hg, and HCO3 of 22 to 26 mEq/L. Uncompensated metabolic acidosis values include a pH below 7.35, PACO2 of 35 to 45 mm Hg, and HCO3 above 22 mEq/L. Compensated metabolic acidosis values include a pH of 7.35 to 7.39, PACO2 below 35 mm Hg, and HCO3- below 22 mEq/L. Compensated respiratory acidosis values include a pH of 7.35 to 7.35, PACO2 above 45 mm Hg, and HCO3 above 26 mEq/L.

32. V/Q scans are ordered to evaluate the possibility of which of the following? a. Pulmonary emboli b. Acute myocardial infarction c. Emphysema d. Acute respiratory distress syndrome

ANS: A This test is ordered for the evaluation of pulmonary emboli. Electrocardiography or cardiac enzymes are ordered to evaluate for myocardial infarction; arterial blood gas analysis, chest radiography, and pulmonary function tests are ordered to evaluate for emphysema. Chest radiography and hemodynamic monitoring are ordered for evaluation of acute respiratory distress syndrome.

Which information about a patient who is receiving cisatracurium (Nimbex) to prevent asynchronous breathing with the positive pressure ventilator requires immediate action by the nurse? a. Only continuous IV opioids have been ordered. b. The patient does not respond to verbal stimulation. c. There is no cough or gag when the patient is suctioned. d. The patient's oxygen saturation fluctuates 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 oxygen 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. Suction the endotracheal tube every 2 to 4 hours. c. Limit the use of positive end-expiratory pressure. d. Give enteral feedings at no more than 10 mL/hr.

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.

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 next? a. Increase the oxygen flow rate. b. Suction the patient's oropharynx. c. Instruct the patient to cough and deep breathe. d. Help the patient to sit in a more upright position.

ANS: A Increasing oxygen flow rate will usually improve oxygen 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 admitting a patient with possible respiratory failure with a high PaCO2, which assessment information should be immediately reported to the health care provider? a. The patient is 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 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) 80%, tidal volume 450, rate 16/minute, and positive end-expiratory pressure (PEEP) 5 cm. Which assessment finding is most important for the nurse to report to the health care provider? a. Oxygen saturation 99% b. Respiratory rate 22 breaths/minute c. Crackles audible at lung bases d. Heart rate 106 beats/minute

ANS: A The FIO2 of 80% increases the risk for oxygen 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 need to be urgently reported to the health care provider.

The nurse is caring for a 33-year-old 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/minute.

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.

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 b. On the right side c. In the tripod position 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 nurse reviews the electronic medical 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? a. Albumin level and recent weight loss b. Mild confusion and recent weight loss c. Age and recent arthroscopic procedure. d. Anemia and recent arthroscopic procedure

ANS: A 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 patient with acute respiratory distress syndrome (ARDS) is placed in the prone position. When prone positioning is used, 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.

. Which of the following should be used when suctioning a mechanically ventilated patient? (Select all that apply.) a. Three hyperoxygenation breaths (breaths at 100% FiO2) b. Hyperinflation (breaths at 150% tidal volume) c. Limit the number of passes to three. d. Instill 5 to 10 mL of normal saline to facilitate secretion removal. e. Use intermittent suction to avoid damaging tracheal tissue.

ANS: A, B, C Hyperoxygenation, hyperinflation, and limiting the number of passes help avoid desaturation. There is no evidence to suggest that intermittent suction reduces damage, and saline instillation can actually increase the risk for infection.

1. Which of the following regarding the client history will assist the nurse in developing the plan of management? (Select all that apply.) a. Provides direction for the rest of the assessment b. Exposes key clinical manifestations c. Aids in developing the plan of care d. The degree of the client's distress determines the extent of the interview e. Determines length of stay in the hospital setting

ANS: A, B, C, D The initial presentation of the patient determines the rapidity and direction of the interview. For a patient in acute distress, the history should be curtailed to just a few questions about the patient's chief complaint and precipitating events.

1. Complications of ETT tubes include (Select all that apply.) a. tracheoesophageal fistula. b. cricoid abscess. c. tracheal stenosis. d. tube obstruction. e. tube displacements.

ANS: A, B, C, D, E Complications of endotracheal tubes include tube obstruction, tube displacement, sinusitis and nasal injury, tracheoesophageal fistula, mucosal lesions, laryngeal or tracheal stenosis, and cricoid abscess.

18. A patient was admitted to the critical care unit with acute respiratory failure. The patient has been on a ventilator for 3 days and is being considered for weaning. The ventilator high-pressure alarm keeps going off. When you enter the room, the ventilator inoperative alarm sounds. Which of the following criteria would indicate that the patient is ready to be weaned? a. FiO2 greater than 50% b. Rapid shallow breathing index less than 105 c. Minute ventilation greater than 10 L/min d. Vital capacity/kg greater than or equal to 15 mL

ANS: B The rapid shallow breathing index (RSBI) has been shown to be predictive of weaning success. To calculate the RSBI, the patient's respiratory rate and minute ventilation are measured for 1 minute during spontaneous breathing. The measured respiratory rate is then divided by the tidal volume (expressed in liters). An RSBI less than 105 is considered predictive of weaning success. If the patient meets criteria for weaning readiness and has an RSBI less than 105, a spontaneous breathing trial can be performed.

2. Deviation of the trachea occurs in which of the following conditions? (Select all that apply.) a. Pneumothorax b. Pulmonary fibrosis c. Chronic obstructive pulmonary disease d. Emphysema e. Pleural effusion

ANS: A, B, E Assessment of tracheal position assists in the diagnosis of pneumothorax, unilateral pneumonia, pulmonary fibrosis, and pleural effusion.

4. Identify the clinical manifestations associated with oxygen toxicity. (Select all that apply.) a. Substernal chest pain that increases with deep breathing b. Moist cough and tracheal irritation c. Pleuritic pain occurring on inhalation, followed by dyspnea d. Increasing CO2 e. Sore throat and eye and ear discomfort

ANS: A, C, E A number of clinical manifestations are associated with oxygen toxicity. The first symptom is substernal chest pain that is exacerbated by deep breathing. A dry cough and tracheal irritation follow. Eventually, definite pleuritic pain occurs on inhalation followed by dyspnea. Upper airway changes may include a sensation of nasal stuffiness, sore throat, and eye and ear discomforts.

42. Place the steps for analyzing arterial blood gases in the proper order. 1. Assess HCO3- level for metabolic abnormalities. 2. Assess PaO2 for hypoxemia. 3. Examine PaCO2 for acidosis or alkalosis. 4. Re-examine pH to determine level of compensation. 5. Examine pH for acidemia or alkalemia. a. 5, 1, 2, 4, 3 b. 5, 3, 1, 4, 2 c. 1, 2, 4, 3, 5 d. 1, 3, 4, 5, 2

ANS: B A methodic approach when assessing arterial blood gases allows the nurse to detect subtle changes. A methodic approach includes look at the Pao2 level, look at the pH level, look at the Paco2 level, look at the HCO3-, and look again at the pH level.

33. A patient with chronic obstructive pulmonary disease requires intubation. After the physician intubates the patient, the nurse auscultates for breath sounds. Breath sounds are questionable in this patient. Which action would best assist in determining endotracheal tube placement in this patient? a. Stat chest radiographic examination b. End-tidal CO2 monitor c. V/Q scan d. Pulmonary artery catheter insertion

ANS: B Although a stat chest radiography examination would be helpful, it has a long turnaround time, and the patient's respiratory status can deteriorate quickly. An end-tidal CO2 monitor gives an immediate response, and the tube can then be reinserted without delay if incorrectly placed. The other tests are not for endotracheal tube placement.

35. Which of the following patients would be considered hypoxemic? a. A 70-year-old man with a PaO2 of 72 b. A 50-year-old woman with a PaO2 of 65 c. An 84-year-old man with a PaO2 of 96 d. A 68-year-old woman with a PaO2 of 80

ANS: B Normal PaO2 is 80 to 100 mm Hg in persons younger than 60 years. The formula for determining PaO2 for a person older than 60 years of age is 80 mm Hg minus 1 mm Hg for every year of age above 60 years of age, for example, 70 years old = 80 mm Hg - 10 mm Hg = 70 mm Hg; 84 years old = 80 mm Hg - 20 mm Hg = 60 mm Hg; and 68 years old = 80 mm Hg - 8 mm Hg = 72 mm Hg.

34. A patient's pulse oximeter alarm goes off. The monitor reads 82%. What is the first action the nurse should perform? a. Prepare to intubate. b. Assess the patient's condition. c. Turn off the alarm and reapply the oximeter sensor. d. Increase O2 level to 4L/NC.

ANS: B The first nursing action would be to assess the patient to see if there is a change in his or her condition. If the patient is stable, then the nurse would turn off the alarm and reapply the oximeter sensor. The pulse oximeter cannot differentiate between normal and abnormal hemoglobin. Elevated levels of abnormal hemoglobin falsely elevate the Spo2. The ability of a pulse oximeter to detect hypoventilation is accurate only when the patient is breathing room air. Because most critically ill patients require some form of oxygen therapy, pulse oximetry is not a reliable method of detecting hypercapnia and should not be used for this purpose.

29. A patient presents with the following values: pH, 7.20; paO2, 106 mm Hg; paCO2, 35 mm Hg; and HCO3-, 11 mEq/L. These values are most consistent with a. uncompensated respiratory acidosis. b. uncompensated metabolic acidosis. c. uncompensated metabolic alkalosis. d. uncompensated respiratory alkalosis.

ANS: B The pH indicates acidosis, and the HCO3- is markedly decreased, indicating a metabolic disorder. Uncompensated metabolic acidosis values include a pH below 7.35, PACO2 of 35 to 45 mm Hg, and HCO3- above 22 mEq/L. Uncompensated respiratory acidosis values include a pH below 7.35, PACO2 above 45 mm Hg, and HCO3- of 22 to 26 mEq/L. Uncompensated respiratory alkalosis values include a pH above 7.45, PACO2 below 35 mm Hg, and HCO3- of 22 to 26 mEq/L. Uncompensated metabolic alkalosis values include a pH above 7.45, PACO2 of 35 to 45 mm Hg, and HCO3- above 26 mEq/L.

A patient admitted with acute respiratory failure has a nursing diagnosis of ineffective airway clearance related to thick, secretions. Which action is a priority for the nurse to include in the plan of care? 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 >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) in order 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 family members of a patient with ARDS 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% oxygen 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.

A patient with acute respiratory distress syndrome (ARDS) and acute kidney injury has the following medications ordered. Which medication should the nurse discuss with the health care provider before giving? a. Pantoprazole (Protonix) 40 mg IV b. Gentamicin (Garamycin) 60 mg IV c. Sucralfate (Carafate) 1 g per nasogastric tube d. Methylprednisolone (Solu-Medrol) 60 mg IV

ANS: B 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 medications are appropriate for the patient with ARDS.

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. Blood urea nitrogen (BUN) level 32 mg/dL b. Red-brown drainage from orogastric tube c. Scattered coarse crackles heard throughout lungs d. Arterial blood gases: pH 7.31, PaCO2 50, PaO2 68

ANS: B The nasogastric drainage indicates possible gastrointestinal bleeding and/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.

The oxygen saturation (SpO2) for a patient with left lower lobe pneumonia is 90%. The patient has rhonchi, a weak cough effort, and complains of fatigue. Which action is a priority for the nurse to take? 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 2-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 2-hour rest period at this time may allow the oxygen 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/minute and an oxygen saturation (SpO2) of 88%. The patient is increasingly lethargic. Which intervention will the nurse anticipate? a. Administration of 100% oxygen 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. Administration of high flow oxygen 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.

To evaluate the effectiveness of ordered interventions for a patient with ventilatory failure, which diagnostic test will be most useful to the nurse? a. Chest x-ray b. Oxygen 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.

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.

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.

1. Which actions should the nurse initiate 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. Elevate the head of the bed to at least 30°. d. Give prescribed pantoprazole (Protonix). 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.

41. A patient is admitted with acute respiratory failure attributable to pneumonia. Smoking history reveals that the patient smoked two packs of cigarettes a day for 25 years, stopping 10 years ago. ABG values on the current ventilator settings are pH, 7.37; PaCO2, 50 mm Hg; and HCO3-, 27 mEq/L. Chest radiograph reveals a large right pleural effusion. Intrapulmonary shunting value of 35% indicates a. normal gas exchange of venous blood. b. an abnormal finding indicative of a shunt-producing disorder. c. a serious and potentially life-threatening condition. d. metabolic alkalosis.

ANS: C A shunt greater than 10% is considered abnormal and indicative of a shunt-producing disorder. A shunt greater than 30% is a serious and potentially life-threatening condition that requires pulmonary intervention.

1. Which of the following causes of hypoxemia is the result of blood passing through unventilated portions of the lungs? a. Alveolar hypoventilation b. Dead space ventilation c. Intrapulmonary shunting d. Drug overdose

ANS: C Hypoxemia is the result of impaired gas exchange and is the hallmark of acute respiratory failure. Hypercapnia may be present, depending on the underlying cause of the problem. The main causes of hypoxemia are alveolar hypoventilation, ventilation/perfusion (V/Q) mismatching, and intrapulmonary shunting. Intrapulmonary shunting occurs when blood passes through a portion of a lung that is not ventilated. Drug overdose is an extrapulmonary cause that affects the brain.

24. On admission, a patient presents as follows: pH, 7.38; respiratory rate, 24 breaths/min, regular, pursed-lip breathing; PaO2, 66 mm Hg; heart rate, 112 beats/min, sinus tachycardia; PaCO2, 52 mm Hg; blood pressure, 110/68 mm Hg; HCO3, 34 mEq/L; and SpO2, 90% on O2 2 L/min nasal cannula. These gases show a. uncompensated metabolic alkalosis. b. uncompensated respiratory acidosis. c. compensated respiratory acidosis. d. compensated respiratory alkalosis.

ANS: C The pH is closer to the acidic level, so the primary disorder is acidosis. Compensated respiratory acidosis values include a pH of 7.35 to 7.39, PACO2 greater than 45 mm Hg, and HCO3 greater than 26 mEq/L.Uncompensated respiratory acidosis values include a pH below 7.35, PACO2 above 45 mm Hg, and HCO3- of 22 to 26 mEq/L. Compensated respiratory alkalosis values include a pH of 7.41 to 7.45, PACO2below 35 mm Hg, and HCO3 below 22 mEq/L. Uncompensated metabolic alkalosis values include a pH above 7.45, PACO2 of 35 to 45 mm Hg, and HCO3- above 26 mEq/L.

19. A patient was admitted to the critical care unit with acute respiratory failure. The patient has been on a ventilator for 3 days and is being considered for weaning. The ventilator high-pressure alarm keeps going off. When you enter the room, the ventilator inoperative alarm sounds. Which of the following criteria would indicate that the patient is not tolerating weaning? a. A decrease in heart rate from 92 to 80 beats/min b. An SpO2 of 92% c. An increase in respiratory rate from 22 to 38 breaths/min d. Spontaneous tidal volumes of 300 to 350 mL

ANS: C Weaning intolerance indicators include (1) a decrease in level of consciousness; (2) a systolic blood pressure increased or decreased by 20 mm Hg; (3) a diastolic blood pressure greater than 100 mm Hg; (4) a heart rate increased by 20 beats/min; (5) premature ventricular contractions greater than 6/min, couplets, or runs of ventricular tachycardia; (6) changes in ST segment (usually elevation); (7) a respiratory rate greater than 30 breaths/min or less than 10 breaths/min; (8) a respiratory rate increased by 10 breaths/min; (9) a spontaneous tidal volume less than 250 mL; (10) a PaCO2 increased by 5 to 8 mm Hg or pH less than 7.30; (11) an SpO2less than 90%; (12) use of accessory muscles of ventilation; (13) complaints of dyspnea, fatigue, or pain; (14) paradoxical chest wall motion or chest abdominal asynchrony; (15) diaphoresis; and (16) severe agitation or anxiety unrelieved with reassurance.

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 respirations have decreased from 30 to 10 breaths/minute. d. The patient's pulse oximetry indicates an O2 saturation of 91%.

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

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 oxygen saturation.

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. insertion of a pulmonary artery catheter. d. positioning the patient for a chest x-ray.

ANS: C 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.

The nurse documents the vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature 101.2° F, blood pressure 90/56 mm Hg, pulse 92, respirations 34. 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.

26. On admission, a patient presents as follows: pH, 7.38; respiratory rate, 24 breaths/min, regular, pursed-lip breathing; PaO2, 66 mm Hg; heart rate, 112 beats/min, sinus tachycardia; PaCO2, 52 mm Hg; blood pressure, 110/68 mm Hg; HCO3, 24 mEq/L; and SpO2, 90% on O2 2 L/min nasal cannula. What treatment would the physician or nurse practitioner likely order for this patient? a. Increase O2 to 6 L/min. b. Prepare for emergency intubation. c. Administer 1 ampule of sodium bicarbonate. d. Repeat ABG testing in 4 hours.

ANS: D Increasing the FiO2 on this patient could decrease the respiratory rate and increase the severity of the patient's CO2 retention. The patient's arterial blood gas (ABG) values do not warrant intubation at this time. Additional sodium bicarbonate is not indicated because this patient has a fully compensated pH. A repeat ABG may be ordered to assess the patient's ongoing respiratory status. Other factors must be considered when reviewing a patient's ABGs, including oxygen saturation, oxygen content, base excess and deficit, and anion gap analysis.

Supplemental oxygen administration is usually effective in treating hypoxemia related to a. physiologic shunting. b. dead space ventilation. c. hypercapnia with a PaCO2 of 35 mm Hg. d. ventilation/perfusion mismatching.

ANS: D Supplemental oxygen administration is effective in treating hypoxemia related to alveolar hypoventilation and ventilation/perfusion mismatching. When intrapulmonary shunting exists, supplemental oxygen alone is ineffective. In this situation, positive pressure is necessary to open collapsed alveoli and facilitate their participation in gas exchange. Positive pressure is delivered via invasive and noninvasive mechanical ventilation. If the patient is also experiencing hypercapnia, the PaCO2 will be greater than 45 mm Hg. In patients with chronically elevated PaCO2 levels, these criteria must be broadened to include a pH less than 7.35.

36. Which blood gas parameter is the acid-base component that reflects kidney function? a. pH b. PaO2 c. PaCO2 d. HCO3-

ANS: D The bicarbonate (HCO3-) is the acid-base component that reflects kidney function. The bicarbonate is reduced or increased in the plasma by renal mechanisms. The normal range is 22 to 26 mEq/L. pH measures the hydrogen ion concentration of plasma. PaO2 measures partial pressure of oxygen dissolved in arterial blood plasma. PaCO2 measures the partial pressure of carbon dioxide dissolved in arterial blood plasma.

25. On admission, a patient presents as follows: pH, 7.38; respiratory rate, 24 breaths/min, regular, pursed-lip breathing; PaO2, 66 mm Hg; heart rate, 112 beats/min, sinus tachycardia; PaCO2, 52 mm Hg; blood pressure, 110/68 mm Hg; HCO3-, 24 mEq/L; and SpO2, 90% on O2 2 L/min nasal cannula. Which of the following diagnoses would be most consistent with the above arterial blood gas values? a. Acute pulmonary embolism b. Acute myocardial infarction c. Congestive heart failure d. Chronic obstructive pulmonary disease

ANS: D The fact that the HCO3- level has increased enough to compensate for the increased pCO2 level indicates that this is not an acute condition because the kidneys can take several days to adjust. The other choices would present with a lower HCO3- level. The values indicate respiratory acidosis, and one of the potential causes is chronic obstructive pulmonary disease. Potential causes for respiratory alkalosis are pulmonary embolism, acute myocardial infarction, and congestive heart failure.

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. Notify the health care provider. b. Check pupils for reaction to light. 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 oxygen 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 action will the nurse anticipate taking next? a. Increase the tidal volume and respiratory rate. b. Increase 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 pneumothorax.

The major hemodynamic consequence of massive pulmonary embolus is: A. increased systemic vascular resistance leading to left heart failure. B. pulmonary hypertension, which ultimately leads to right heart failure. C. obstruction of the portal vein, which leads to ascites. D. embolism to the internal carotids, which results in stroke.

B (The major hemodynamic consequence of massive pulmonary embolus is pulmonary hypertension, which ultimately leads to right heart failure.)

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 caring for a 78-year-old 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. Scattered crackles bilaterally in the posterior lung bases. b. Persistent cough that is productive of blood-tinged sputum. c. Temperature of 101.5° F (38.6° C) after 2 days of IV antibiotic therapy. d. Decreased oxygen saturation to 90% with 100% O2 by non-rebreather mask.

ANS: D 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.

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 oxygen and use of positive pressure ventilation. The other patients should also be assessed as quickly as possible, but their assessment data are typical of their disease processes and do not suggest deterioration in their status.

Hypoxemic ARF respiratory causes

ARDS, pneumonia, toxic inhalation, hepatopulmonary syndrome, pulmonary embolism, pulmonary artery laceration and hemorrhage, inflammatory state

Hypoxemic ARF Cardiac causes

Anatomic shunt, cardiogenic pulmonary edema, shock r/t decrease blood to lungs, high CO means diffusion limitation

hypercapnic ARF neuromuscular system causes

Myasthenia gravis, Guillain-Barre syndrome, multiple sclerosis, muscular dystrophy, phrenic nerve injury, acute myopathy

Hypoxemic Respiratory failure mechanism

V/Q mismatch Shunt Diffusion limitation Alveolar hypoventilation

Usual causes of Type I respiratory failure.

V/Q mismatching, intrapulmonary shunting,

Major respiratory problems related to pathophysiology of ARDS include: A. decreased lung compliance caused by increased membrane permeability. B. decreased airway resistance secondary to overdistended alveoli. C. overproduction of surfactant, which causes increased surface tension. D. bronchodilation, which decreases the amount of air flow into the lungs.

a (During ARDS, increased membrane permeability allows an influx of fluids and other large molecules into the lung tissues, which results in decreased lung compliance.)

Usual cause of Type II respiratory failure.

alveolar hypoventilation

shunt

anatomic shunt: blood bypasses the lungs intrapulmonary shunt: blood pass pulmonary capillary w/o gas exchange due to fluid in alveolar

Hypercapnic ARF Respiratory causes

asthma, copd, cystic fibrosis

hypercapnic ARF CNS causes

brainstem injury, sedative and opioid overdose, spinal cord injury, head injury

Which of the following is most likely to cause respiratory alkalosis in a patient? A. airway obstruction from biting on the endotracheal tube B. pulmonary edema from receiving too much IV fluid too quickly C. excess tidal volume in a mechanically ventilated patient D. overuse of antacids, especially those containing aluminum hydroxide

c (When a ventilated patient receives excess tidal volume, too much CO2 is blown off. This results in production of respiratory alkalosis.)

Supplemental oxygen alone is NOT effective in treating hypoxemia caused by... a. alveolar hypoventilation b. V/Q mismatching c. intrapulmonary shunting d. noninvasive ventilation

c (When intrapulmonary shunting exists, supplementary oxygen alone is ineffective. Positive pressure is needed to open collapsed alveoli and facilitate their participation in gas exchange).

V/Q mismatch

cause by COPD, pneumonia, asthma, atelectasis, increase O2 demand but ventilation is limited pulmonary embolus affect perfusion

diffusion limitation

gas exchange is blocked by thicken, damage or destroy alveolar. Worsen by COPD, pulmonary emboli, pulmonary fibrosis, ARDS. No Diffusion Hypoxemia that is present when exercise, blood moving faster through capillary less diffusion time.

Collaborative care for ARDS

give O2, lateral rotation therapy, PEEP ventilation, prone position, permissive hypercapnia, treat underlying cause, hemodynamic monitor, Inotropic and vasopressor medications: dopamine, dobutamine, norepinephrine diuretics IV fluid admin sedation neuromuscular blockade

high PEEP effects

decrease CO and CI. increases intrathoracic pressure and decrease venous return decreasing CO Improve CO by lowering PEEP, admin crystalloid fluid, colloid solution, use inotropic drugs

Manifestation of hypoxemia

dyspnea, tachypnea, prolonged expiration, intercoastal muscle retraction, agitation, disorientation, restless, delirium, confusion, tachycardia, htn, cool and clammy, fatigue, cyanosis

manifestation of hypercapnia

dyspnea, tripod position, purse lip breathing, morning HA, disorientation, progressive somnolence, . Dysrhythmias, htn, tachycardia, bounding pulse, muscle weakness, decrease tendon reflexes, tremors, seizures

Ventilator associate pneumonia prevention

elevate head 30-45 degrees, daily sedation holiday, peptic ulcer prophylaxis, venous thromboemoblism prophylaxis, daily oral care with chlorhexidine

alveolar hypoventilation

from restrictive lung disease, cns disease, chest dysfunction, acute asthma, neuromuscular disease. Primary cause hypercapnic failure. air trapping

hypercapnic ARF chest wall causes

thoracic trauma, kyphoscoliosis, pain, severe obesity

In _____________ respiratory failure, PaO2 is low, PaCO2 is normal.

type I