Acute Respiratory Distress Syndrome
Which complication is associated with mechanical ventilation? A. gastrointestinal hemorrhage B. immunosuppression C. increased cardiac output D. pulmonary emboli
A Gastrointestinal hemorrhage occurs in about 25% of clients receiving prolonged mechanical ventilation because of the development of stress ulcers. Clients who are receiving steroid therapy and those with a previous hx of ulcers are most likely to be at risk. Other possible complications include incorrect ventilation, oxygen toxicity, fluid imbalance, decreased cardiac output, pneumothorax, infection and atelectasis.
A client has the following arterial blood gas values: pH 7.52 PaO2 50 mm Hg (6.7 kPa) PaCO2 28 mm Hg (3.72 kPa) HCO3 24 mEq/L (24 mmol/L) Based upon the client's PaO2, which conclusion would be accurate? A. The client is severely hypoxic B. The Oxygen level is low but poses no risk for the client C. The client's PaO2 level is within normal range D. The client requires oxygen therapy with very low oxygen concentrations
A Normal PaO2 level ranges from 80-100 mm Hg. When PaO2 falls to 50 mm Hg, the nurse should be alert for signs of hypoxia and impending respiratory failure. An oxygen level this low poses a sever risk for respiratory failure. The client will require oxygenation at a concentration that maintains the PaO2 at 55-60 mm Hg or more.
Which condition can place a client at risk for acute respiratory distress syndrome (ARDS)? A. septic shock B. chronic obstructive pulmonary disease C. asthma D. heart failure
A The two risk factors most commonly associated with the development of ARDS are gram-negative septic shock and gastric content aspiration. Nurses should be particularly vigilant in assessing a client for onset of ARDS if the client has experienced direct lung trauma or a systemic inflammatory response syndrome. COPD, asthma, and HF are not direct causes of ARDS.
The nurse is caring for a group of clients on a pulmonary unit. The nurse can delegate which task to unlicensed assistive personnel (UAP)? A. Assisting a client with adjusting his or her nasal cannula B. making adjustments to flow rates based on client responses C. monitoring a client for adverse effects of oxygen therapy D. assessing a client for the best method of oxygen delivery
A UAP can assist a client with the adjustment of his or her oxygen delivery device. Making adjustments based on client responses, monitoring for adverse effects and assessing for the best method of oxygen delivery are skills that require nursing judgments and can only be performed by a nurse.
A nurse receives the taped change-of-shift report for assigned clients and prioritizes client rounds. In what order from first to last should the nurse assess these clients? All options must be used. A. a client who has an endotracheal tube and who will be transferred to a long-term respiratory care unit that day. B. a client with type 2 diabetes who had a cerebrovascular accident 4 days ago C. A cleint with cellulitis of the left lower extremity with a fever of 100.8 F (38.2C) D. a client receiving D5W IV at 125 mL/h with 75 mL remaining
A, C, D, B Because two major complications of ET tube intubation, inadvertent extubation and aspiration, can be catastrophic events, assessment of this client is the first priory. cellulitis is a serious infection as there is inflammation of subcutaneous tissues; third spacing of fluid may promote the formation of FVD, which can be exacerbated by the fever due to insensible fluid loss. The nurse should assess this client next to determine current VS and fluid status. The nurse should assess the client with the IV fluids next because the new nag of fluids will need to be hung in 30-40 minutes. IV therapy necessitates that the client be assessed for signs and symptoms of adequate hydration, and the IV access site needs to be assessed. From the information provided, there is no indication that the client who had the cerebrovascular accident is unstable. Thus this client is the last priority for assessment.
A client with acute respiratory distress syndrome (ARDS) has fine crackles at lung bases, and the respirations are shallow at a rate of 28 breaths/ min. The client is restless and anxious. In addition to monitoring the arterial blood gas results, what should the nurse do? Select all that apply. A. monitor serum creatinine and blood urea nitrogen levels. B. administer a sedative. C. Keep the head of the bed flat. D. Administer humidified oxygen. E. Auscultate the lungs.
A, D, E Acute respiratory distress syndrome (ARDS) may cause renal failure and superinfection, so the nurse should monitor urine output and urine chemistries. Treatment of hypoxemia can be complicated because changes in lung tissue leave less pulmonary tissue available for gas exchange, thereby causing inadequate perfusion. Humidified oxygen may be one means of promoting oxygenation. The client has crackles in the lung bases, so the nurse should continue to assess breath sounds. Sedatives should be used with caution in clients with ARDS. The nurse should try other measures to relieve the client's restlessness and anxiety. The head of the bed should be elevated to 30 degrees to promote chest expansion and prevent atelectasis
The nurse interprets which finding as an early sign of acute respiratory distress syndrome (ARDS) in a client at risk? A. elevated carbon dioxide level B. hypoxia not responsive to oxygen therapy C. metabolic acidosis D. sever, unexplained electrolyte imbalance
B A hallmark of early ARDS is refractory hypoxemia. The client's PaO2 level continues to fall, despite higher concentrations of administered oxygen. Elevated carbon dioxide and metabolic acidosis occur late in the disorder. Severe electrolyte imbalances are not indicators of ARDS.
While making rounds, the nurse finds a client with COPD sitting in a wheelchair, slumped over a lunch tray. After determining the client is unresponsive and calling for help, the nurse's first reaction should be to: A. push the "code blue" (emergency response) button. B. Call the rapid response team C. Open the client's airway D. Call for a difibrillator
C
Which action should the nurse anticipate in a client who has been diagnosed with acute respiratory distress syndrome (ARDS)? A. tracheostomy B. use of a nasal cannula C. mechanical ventilation D. insertion of a chest tube
C Endotracheal intubation and mechanical ventilation are required for ARDS to maintain adequate respiratory support. Endotracheal intubation, not a tracheostomy, is usually the initial method of maintaining an airway. The client requires mechanical ventilation; nasal oxygen will not provide adequate oxygenation. Chest tubes are used to remove air or fluid form intrapleural spaces.
Which nursing interventions would be most likely to prevent the development of acute respiratory distress syndrome (ARDS)? A. teaching cigarette smoking cessation B. maintaining adequate serum potassium levels C. monitoring the clients for signs of hypercapnia D. replacing fluids adequately during hypovolemic states
D One of the major risk factors for developing ARDS is hypovolemic shock. Adequate fluid replacement is essential to minimize the risk of ARDS in these clients. Teaching smoking cessation does not prevent ARDS. An abnormal serum potassium level and hypercapnia are not risk factors for ARDS.
Which assessment is most appropriate for determining the correct placement of an endotracheal tube in a mechanically ventilated client? A. assessing the client's skin color B. monitoring the respiratory rate C. verifying the amount of cuff inflation D. auscultating breath sounds bilaterally
D Auscultation for bilateral breath sounds is the most appropriate method for determining cuff placement. The nurse should also look for the symmetrical rise and fall the the chest and should note the location of the exit mark on the tube. Assessments of skin color, respiratory rate, and the amount of cuff inflation cannot validate the placement of the ET Tube.
A client, diagnosed with acute pancreatitis 5 days ago, is experiencing respiratory distress. Which finding should the nurse report to the healthcare provider? A. Arterial oxygen level of 46 mm Hg (6.1 kPa) B. respirations of 12 breaths/min C. lack of adventitious lung sounds D. Oxygen saturation of 96% on room air
A Manifestations of ARDS secondary to acute pancreatitis include respiratory distress, tachypnea, dyspnea, fever, dry cough, fine crackles heard throughout lung fields, possible confusion and agitation and hypoxemia with arterial oxygen level below 50 mm Hg. The nurse should report the arterial oxygen level of 46 to the HCP. A respiratory rate of 12 is normal and not considered a sign of respiratory distress. Adventitious lung sounds such as crackles, are typically found in clients with ARDS. Oxygen saturation of 96% is satisfactory and does not represent hypoxemia or low arterial oxygen saturation.
A client with acute respiratory distress syndrome (ARDS) is on a ventilator. The client's peak inspiratory pressures and spontaneous respiratory rate are increasing, and the PO2 is not improving. Using the SBAR technique for communication, the nurse calls the healthcare provider with the recommendation for: A. initiating IV sedation B. starting a high-protein diet C. providing pain medication D. increasing the ventilator rate
A The client may be fighting the ventilator breaths. Sedation is indicated to improve compliance with the ventilator in an attempt to lower peak inspiratory pressures. The workload of breathing does indicate the need for increase protein calories; however, this will not correct the respiratory rate. There is no indication that the client is experiencing pain. Increasing the rate on the ventilator is not indicated with the client's increased spontaneous rate.
The nurse is a member of a team that is planning a client-centered, community-based approach to care of clients with COPD. In which areas should the team focus on improving quality of care and delivery? Select all that apply. A. the community B. clinical information systems C. delivery system designs D. administrative leadership E. acute care setting
A, B, C The process of changing a healthcare system from an acute care model to a community-based care model uses continuous quality improvement methods. The goal s to improve the health of chronically ill clients. Areas for improvement include health systems, delivery system design, decision support, clinical information systems, self-management support, and the community. This system requires healthcare services that care client centered and coordinated among members of the healthcare team and the client and the family. These changes do not focus on the administrative leadership or the care in the acute care setting alone.
The nurse is caring for a client who has been placed on droplet precautions. Which PPE is required to take care of this client? Select all that apply. A. gloves B. gown C. mask D. glasses E. respirator
A, B, C, D Gloves, gown, mask, and eye protection are worn to protect healthcare workers and to help prevent the spread of infection when clients are placed in droplet isolation. Because droplets are too heavy to be airborne, a respirator is not required when caring for a client in droplet precautions.
The nurse's assignment consists of four clients. After receiving shift report, in which order form first to last should the nurse assess these clients? All options must be used. A. an 85-year-old client with bacterial pneumonia, temperature of 102.2 F (42 C), and shortness of breath B. A 60-year-old client with chest tubes who is 2 days postoperative following a thoracotomy for lung cancer and is requesting something for pain. C. a 35-year-old client with suspected TB who has a cough D. a 56-year-old client whti emphysema who has a scheduled dose of bronchodilator due to be administered, with nor report of acute respiratory distress
A, B, D, C
The nurse has received a change of shift report on clients. Which client should the nurse assess first? A. the client with COPD with a PaO2 fo 56 mm Hg who is being discharged home on oxygen B. A client with asthma with respirations of 36 breaths/min whose wheezing has diminshed C. a client with asthma who has a heart rate of 90 bpm and whose beta-blocker is scheduled to be administered now D. a client who is scheduled for an angiogram now and is ready to be transported
B Respirations of 36 breaths/min and diminished wheezing are indicative of respiratory distress. This finding takes precedence over a client scheduled for an angiogram, a client with a HR of 90 bpm needing a scheduled beta-blocker, or a client with a paO2 of 56 mm Hg, which is indicated for a client being discharged home on oxygen.
A client with acute respiratory distress syndrome (ARDS) is showing sings of increased dyspnea. The nurse reviews a report of blood gas values that recently arrived (See report). pH 7.35 PaCO2 25 mm Hg (3.3 kPa) Hco3 22 mEq/L (22mmol/L) PaO2 95 mm Hg (12.6 kPa) Which finding is abnormal? A. pH B. PaCO2 C. HCO3 D. PaO2
B The normal range for PaCO2 is 35-45. Thus, this client's PaCO2 level is low. The client is experience respiratory alkalosis (carbonic acid deficit) due to hyperventilation. The nurse should report this finding to the HCP because it requires intervention. The increase in ventilation decrease the PaCO2 level, which leads to decreased carbonic acid and alkalosis. The bicarbonate level is normal in uncompensated respiratory alkalosis along with the normal PaO2 level. Normal serum pH is 7.35-7.45; in uncompensated respiratory alkalosis, the serum pH is >7.45
The nurse is caring for a client with pneumonia who is confused about time and place and has intravenous fluids infusing. Despite the nurse's attempt to reorient the client and then provide distraction, the client has begun to pull at the IV tubing. After increasing the frequency of observation, in which order should the nurse implement interventions to ensure the client's safety? All options must be used. A. review the client's medications for interactions that may cause or increase confusion B. assess the client's respiratory status including oxygen saturation C. ensure the client does not need toileting or pain medications D. Contact the HCP, and request a prescription for soft wrist restraints
B, C, A, D
A client has developed a hospital-acquired pneumonia. When preparing to administer cephalexin 500 mg, the nurse notices that the pharmacy sent cefazolin. What should the nurse do? Select all that apply. A. administer the cefazolin B. verify the medication prescription as written by the HCP C. contact the pharmacy and speak to a pharmacist D. request that cephalexin be sent promptly E. return the cefazolin to the pharmacy
B, C, D, E One of the five rights of drug administration is right medication. Cefazolin was not the medication prescribed. The pharmacist is the professional resource and serves as a check to ensure that clients receive the right medication. Returning unwanted medications to the pharmacy will decrease the opportunity for a medication error by the nurse who follows the current nurse.
The UAP reports to the RN that a client admitted with pneumonia is very diaphoretic. The nurse reviews the vital signs in the medical record obtained by the UAP. What should the nurse do? Select all that apply 0800: 100.9 90 16 112/74 93% 1000: T-None 104 18 110/68 92% 1200: 101.8 118 24 116/78 92% A. assure the client is maintaining complete bed rest B. check the urine output C. ask the client to drink more fluids D. notify the HCP E. administer acetaminophen as prescribed
B, C, E
The nurse has placed the intubated client with Acute Respiratory Distress Syndrome (ARDS) in prone position for 30 minutes. Which factors would require the nurse to discontinue prone positioning and return the client to the supine position? Select all that apply. A. The family is coming to visit. B. The client has increased secretions requiring frequent suctioning C. The SpO2 and Po2 have decreased. D. The client is tachycardic with drop in blood pressure. E. The face has increased skin breakdown and edema.
C, D, E The prone position is used to improve oxygenation, ventilation and perfusion. The importance of placing clients with ARDS in prone positioning allows for mobilization of secretions, and the nurse can provide suctioning. Clinical judgement must be used to determine the length of time in prone position. If the client's hemodynamic status, oxygenation or kin is compromised, the client should be returned to the supine position for evaluation. Facial edema is expected with the prone position, but the skin breakdown is of concern.
The nurse should use which type of precautions for a client being admitted to the hospital with suspected tuberculosis? A. hand hygiene B. Contact precautions C. droplet precautions D. airborne precautions
D Airborne precautions prevent transmission of infectious agents that remain infectious over long distances when suspended in the air. The preferred placement is in an isolation single-client room that is equipped with special air handling and ventilation. A negative pressure room, or an area that exhausts room air directly outside or through HEPA filters, should be used if re circulation is unavoidable. While hand hygiene is important, it is not sufficient to prevent transmission of TB. Contact precautions are for clients with known or suspected infections or evidence of syndromes that represent an increased risk for contact transmission. Droplet precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Because these pathogens do not remain infectious over long distances, in a healthcare facility, special air handling and ventilation are not required to prevent droplet transmission.
To improve the oxygenation of a client with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation, the nurse should place the client in which position? A. supine B. semi-Fowler's C. Lateral side D. prone
D Prone positioning is used to improve oxygenation in clients with ARDS who are receiving mechanical ventilation. The positioning allows for recruitment of collapsed alveolar units, improvement in ventilation, reduction in shunting, mobiliation of secretions, and improvement in functional reserve capacity (FRC). When the client is supine, side-to-side repositioning should be done every 2 hours with the head of the bed elevated at least 30 degrees.
To promote effective airway clearance in a client with acute respiratory distress, what should the nurse do? A. administer oxygen every 2 hours B. turn the client every 4 hours C. administer sedatives to promote rest D. suction if cough is ineffective
D The nurse should suction the client if the client is not able to cough up secretions and clear the airway. Administering oxygen will not promote airway clearance. The client should be turned q2h to help move secretions; q4h is not often enough. Administering sedatives to promote rest is contraindicated in ARDS because sedatives can depress respirations
A confused client with carbon monoxide poisoning experiences dizziness when ambulating to the bathroom. The nurse should: A. put all four side rails up on the bed B. ask the UAP to place restraints on the client's upper extremities C. request that the client's roommate put the call light on when the client is attempting to get out of bed D. Check on the client at regular intervals to ascertain the need to use the bathroom
D confusion and vertigo are risk factors for falls. Measures must be taken to minimize the risk of injury. The RN or UAP should check on the client regularly to determine needs regarding elimination. Restraints, include bed rails and extremity restraints, should be used only to ensure the person's safety or the safety of others, and there must be a written prescription from a HCP before using them. The nurse should never ask the roommate of a client to be responsible for the client's safety.
