Respiratory Failure and Acute Respiratory Distress Syndrome nclex

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 correct?

"PEEP prevents the lung air sacs from collapsing during exhalation." 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.

After receiving change-of-shift report, which patient will the nurse assess first?

A patient with septicemia who has intercostal and suprasternal retractions rationale: 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 also should be assessed as quickly as possible, but their assessment data are typical of their disease processes and do not suggest deterioration in their status.

To evaluate the effectiveness of prescribed therapies for a patient with ventilatory failure, which diagnostic test will be most useful to the nurse?

Arterial blood gas (ABG) analysis rationale: 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 also may be done to help in assessing oxygenation or determining the cause of the patient's ventilatory failure.

When assessing a patient with chronic lung disease, the nurse finds a sudden onset of agitation and confusion. Which action should the nurse take first?

Assess oxygenation using pulse oximetry. rationale: Since agitation and confusion are frequently the initial indicators of hypoxemia, the nurse's initial action should be to assess oxygen saturation. The other actions also are appropriate, but assessment of oxygenation takes priority over other assessments and notification of the health care provider.

The pulse oximetry for a patient with right lower lobe pneumonia indicates an oxygen saturation of 90%. The patient has rhonchi, a weak cough effort, and complains of fatigue. Which action is best for the nurse to take?

Assist the patient with staged coughing. rationale: 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 right side may cause a further decrease in oxygen saturation because perfusion will be directed more toward the more poorly ventilated lung.

To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care for a patient who requires intubation and mechanical ventilation?

Elevate head of bed to 30 to 45 degrees. rationale: Elevation of the head decreases the risk for aspiration. PEEP 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.

Which of these nursing actions included in the care of a mechanically ventilated patient with acute respiratory distress syndrome (ARDS) can the RN delegate to an experienced LPN/LVN working in the intensive care unit?

Insert a retention catheter rationale: Insertion of retention 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 pulmonary artery pressures require advanced assessment skills and should be done by the RN caring for a critically ill patient.

A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation develops a pneumothorax. Which action will the nurse anticipate taking?

Lower the positive end-expiratory pressure (PEEP). rationale: 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 nurse obtains 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?

Obtain oxygen saturation using pulse oximetry. rationale: 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. Administration of the scheduled antibiotic and administration of Tylenol also will be done, but they are not the highest priority for a patient who may be developing ARDS.

A patient has a nursing diagnosis of ineffective airway clearance related to thick, secretions. Which action will be best for the nurse to include in the plan of care?

Offer the patient fluids at frequent intervals. rationale: Since 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. The use of the incentive spirometer should be more frequent in order to facilitate the clearance of the secretions. The other actions also may be helpful in improving the patient's gas exchange, but they do not address the thick secretions that are causing the poor airway clearance.

The nurse is caring for a patient who was hospitalized 2 days earlier with aspiration pneumonia. Which assessment information is most important to communicate to the health care provider?

Oxygen saturation (SpO2) has dropped to 90% with administration of 100% O2 by non-rebreather mask. rationale: 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.

A patient with ARDS who is receiving mechanical ventilation using synchronized intermittent mandatory ventilation (SIMV) has settings of fraction of inspired oxygen (FIO2) 80%, tidal volume 500, rate 18, and positive end-expiratory pressure (PEEP) 5 cm. Which assessment finding is most important for the nurse to report to the health care provider?

Oxygen saturation 99% rationale: The FIO2 of 80% increases the risk for oxygen toxicity. Since 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.

Which assessment finding by the nurse when caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP) indicates that the PEEP may need to be decreased?

The patient has subcutaneous emphysema. rationale: 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 indications that PEEP should be reduced.

When admitting a patient in possible respiratory failure with a high PaCO2, which assessment information will be of most concern to the nurse?

The patient is somnolent. rationale: 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.

The nurse is caring for a 22-year-old patient who came to the emergency department with acute respiratory distress. Which information about the patient requires the most rapid action by the nurse?

The patient's PaO2 is 45 mm Hg. rationale: 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.

When prone positioning is used in the care of a patient with acute respiratory distress syndrome (ARDS), which information obtained by the nurse indicates that the positioning is effective?

The patient's PaO2 is 90 mm Hg, and the SaO2 is 92%. rationale: 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.

A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department complaining of shortness of breath and dyspnea. Which assessment finding by the nurse is most important to report to the health care provider?

The patient's respiratory rate has decreased from 30 to 10 breaths/min. rationale: 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.

A patient with respiratory failure has a respiratory rate of 8 and an SpO2 of 89%. The patient is increasingly lethargic. The nurse will anticipate assisting with _______________

endotracheal intubation and positive pressure ventilation. rationale: 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. BiPAP requires that the patient initiate an adequate respiratory rate to allow adequate gas exchange.

A patient with acute respiratory distress syndrome (ARDS) and acute renal failure has the following medications prescribed. Which medication should the nurse discuss with the health care provider before administration?

gentamicin (Garamycin) 60 mg IV rationale: 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.

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%. The nurse will ______________

increase the oxygen flow rate. rationale: Increasing oxygen flow rate usually will 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.

A patient develops increasing dyspnea and hypoxemia 2 days after having cardiac surgery. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by left ventricular failure, the nurse will anticipate assisting with ____________

inserting a pulmonary artery catheter. rationale: 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.

When the nurse is caring for an obese patient with left lower lobe pneumonia, gas exchange will be best when the patient is positioned _______________

on the right side. rationale: 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.