67- Acute Respiratory Failure and Acute Respiratory Distress Syndrome

6. When admitting a patient with possible respiratory failure and a high PaCO2, which assessment information should be immediately reported to the health care provider? a. The patient is very 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.

23. Which information about a patient who is receiving cisatracurium (Nimbex) to prevent asynchronous breathing with the positive pressure ventilator requires action by the nurse? a. No sedative has been ordered for the patient. b. The patient does not respond to verbal stimulation. c. There is no cough or gag reflex when the patient is suctioned. d. The patient's oxygen saturation remains 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 O2 saturation is adequate.

13. 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. Give enteral feedings at no more than 10 mL/hr. c. Suction the endotracheal tube every 2 to 4 hours. d. Limit the use of positive end-expiratory pressure.

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.

7. A patient with acute respiratory distress syndrome (ARDS) and acute kidney injury has the following drugs ordered. Which drug should the nurse discuss with the health care provider before giving? a. gentamicin 60 mg IV b. pantoprazole (Protonix) 40 mg IV c. sucralfate (Carafate) 1 g per nasogastric tube d. methylprednisolone (Solu-Medrol) 60 mg IV

ANS: A 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 drugs are appropriate for the patient with ARDS.

22. 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) of 80%, tidal volume of 450, rate of 16/minute, and positive end-expiratory pressure (PEEP) of 5 cm. Which assessment finding is most important for the nurse to report to the health care provider? a. O2 saturation of 99% b. Heart rate 106 beats/minute c. Crackles audible at lung bases d. Respiratory rate 22 breaths/minute

ANS: A The FIO2 of 80% increases the risk for O2 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 be the most important data to report to the health care provider.

19. The nurse is caring for a 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/min.

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.

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

ANS: A The nasogastric drainage indicates possible gastrointestinal bleeding 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.

5. 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.

11. When prone positioning is used for a patient with acute respiratory distress syndrome (ARDS), 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.

14. A patient admitted with acute respiratory failure has ineffective airway clearance related to thick secretions. Which nursing intervention would specifically address this patient problem? 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 above 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) 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.

10. Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the patient's caregiver 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% O2 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.

2. 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? a. Suction the patient's oropharynx. b. Increase the prescribed O2 flow rate. c. Instruct the patient to cough and deep breathe. d. Help the patient to sit in a more upright position.

ANS: B Increasing O2 flow rate will usually improve O2 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.

4. The oxygen saturation (SpO2) for a patient with left lower lobe pneumonia is 90%. The patient has wheezes, a weak cough effort, and complains of fatigue. Which action should the nurse take next? 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 4-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 4-hour rest period at this time may allow the O2 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.

3. A patient with respiratory failure has a respiratory rate of 6 breaths/min and an oxygen saturation (SpO2) of 88%. The patient is increasingly lethargic. Which intervention will the nurse anticipate? a. Administration of 100% O2 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. Giving high-flow O2 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.

9. 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 beats/min.

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 start 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. Give prescribed pantoprazole (Protonix). d. Elevate the head of the bed to at least 30°. 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.

25. 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 O2 saturation.

1. Which diagnostic test will provide the nurse with the most specific information to evaluate the effectiveness of interventions for a patient with ventilatory failure? a. Chest x-ray b. O2 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.

12. The nurse assesses vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature of 101.2° F, blood pressure of 90/56 mm Hg, pulse of 92 beats/min, and respirations of 34 breaths/min. 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.

20. The nurse is caring for an older 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. Persistent cough of blood-tinged sputum. b. Scattered crackles in the posterior lung bases. c. Oxygen saturation 90% on 100% O2 by nonrebreather mask. d. Temperature 101.5° F (38.6° C) after 2 days of IV antibiotics.

ANS: C 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.

17. 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 pulse oximetry indicates a 91% O2 saturation. d. The patient's respirations have dropped to 10 breaths/minute.

ANS: D A drop 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 O2 saturation of 91% is common in patients with COPD and will provide adequate gas exchange and tissue oxygenation.

18. 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. Observe for facial symmetry. b. Notify the health care provider. 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 O2 saturation. The other actions are also appropriate, but assessment of oxygenation takes priority over other assessments and notification of the health care provider.

15. A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation develops a right pneumothorax. Which collaborative action will the nurse anticipate next? a. Increase the tidal volume and respiratory rate. b. Decrease 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 another pneumothorax.

21. 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

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

ANS: D 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.

16. 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 O2 and use of positive-pressure ventilation. The other patients should also be assessed, but their assessment data are typical of their disease processes and do not suggest deterioration in their status.

Patients with acute respiratory failure will have drug therapy to meet their individual needs. Which drugs will meet the goal of reducing pulmonary congestion (select all that apply)? a. Morphine b. Furosemide (Lasix) c. Nitroglycerin (Tridil) d. Albuterol (Ventolin) e. Ceftriaxone (Rocephin) f. Methylprednisolone (Solu-Medrol)

a, b, c. Morphine and nitroglycerin (e.g., Tridil) will decrease pulmonary congestion caused by heart failure; IV diuretics (e.g., furosemide [Lasix]) are also used. Inhaled albuterol (Ventolin) or metaproterenol (Alupent) will relieve bronchospasms. Ceftriaxone (Rocephin) and azithromycin (Zithromax) are used to treat pulmonary infections. Methylprednisolone (Solu-Medrol), an IV corticosteroid, will reduce airway inflammation. Morphine is also used to decrease anxiety, agitation, and pain.

Evolve 1. Which signs and symptoms distinguish hypoxemic from hypercapnic respiratory failure? (select all that apply) a. Cyanosis b. Tachypnea c. Morning headache d. Paradoxical breathing e. Use of pursed-lip breathing

a, b, d,

What are the primary pathophysiologic changes that occur in the injury or exudative phase of ARDS (select all that apply)? a. Atelectasis b. Shortness of breath c. Interstitial and alveolar edema d. Hyaline membranes line the alveoli e. Influx of neutrophils, monocytes, and lymphocytes

a, c, d. The injury or exudative phase is the early phase of ARDS when atelectasis and interstitial and alveoli edema occur and hyaline membranes composed of necrotic cells, protein, and fibrin line the alveoli. Together, these decrease gas exchange capability and lung compliance. Shortness of breath occurs but it is not a physiologic change. The increased inflammation and proliferation of fibroblasts occurs in the reparative or proliferative phase of ARDS, which occurs 1 to 2 weeks after the initial lung injury.

Which changes of aging contribute to the increased risk for respiratory failure in older adults (select all that apply)? a. Alveolar dilation b. Increased delirium c. Changes in vital signs d. Increased infection risk e. Decreased respiratory muscle strength f. Diminished elastic recoil within the airways

a, d, e, f. Changes from aging that increase the older adult's risk for respiratory failure include alveolar dilation, increased risk for infection, decreased respiratory muscle strength, and diminished elastic recoil in the airways. Although delirium can complicate ventilator management, it does not increase the older patient's risk for respiratory failure. The older adult's blood pressure (BP) and heart rate (HR) increase but this does not affect the risk for respiratory failure. The ventilatory capacity is decreased and the larger air spaces decrease the surface area for gas exchange, which increases the risk.

The patient progressed from acute lung injury to acute respiratory distress syndrome (ARDS). He is on the ventilator and receiving propofol (Diprivan) for sedation and fentanyl (Sublimaze) to decrease anxiety, agitation, and pain in order to decrease his work of breathing, O2 consumption, carbon dioxide production, and risk of injury. What intervention is recommended in caring for this patient? a. A sedation holiday b. Monitoring for hypermetabolism c. Keeping his legs still to avoid dislodging the airway d. Repositioning him every 4 hours to decrease agitation

a. A sedation holiday is needed to assess the patient's condition and readiness to extubate. A hypermetabolic state occurs with critical illness. With malnourished patients, enteral or parenteral nutrition is started within 24 hours; with well-nourished patients it is started within 3 days. With these medications, the patient will be assessed for cardiopulmonary depression. Venous thromboembolism prophylaxis will be used but there is no reason to keep the legs still. Repositioning the patient every 2 hours may help to decrease discomfort and agitation

Although ARDS may result from direct lung injury or indirect lung injury as a result of systemic inflammatory response syndrome (SIRS), the nurse is aware that ARDS is most likely to occur in the patient with a host insult resulting from a. sepsis. b. oxygen toxicity. c. prolonged hypotension. d. cardiopulmonary bypass.

a. Although ARDS may occur in the patient who has virtually any severe illness and may be both a cause and a result of systemic inflammatory response syndrome (SIRS), the most common precipitating insults of ARDS are sepsis, gastric aspiration, and severe massive trauma.

Which assessment finding should cause the nurse to suspect the early onset of hypoxemia? a. Restlessness b. Hypotension c. Central cyanosis d. Cardiac dysrhythmias

a. Because the brain is very sensitive to a decrease in oxygen delivery, restlessness, agitation, disorientation, and confusion are early signs of hypoxemia, for which the nurse should be alert. Mild hypertension is also an early sign, accompanied by tachycardia. Central cyanosis is an unreliable, late sign of hypoxemia. Cardiac dysrhythmias also occur later

After endotracheal intubation and mechanical ventilation have been started, a patient in respiratory failure becomes very agitated and is breathing asynchronously with the ventilator. What is it most important for the nurse to do first? a. Evaluate the patient's pain level, ABGs, and electrolyte values b. Sedate the patient to unconsciousness to eliminate patient awareness c. Administer the PRN vecuronium (Norcuron) to promote synchronous ventilations d. Slow the rate of ventilations provided by the ventilator to allow for spontaneous breathing by the patient

a. It is most important to assess the patient for the cause of the restlessness and agitation (e.g., pain, hypoxemia, electrolyte imbalances) and treat the underlying cause before sedating the patient. Although sedation, analgesia, and neuromuscular blockade are often used to control agitation and pain, these treatments may contribute to prolonged ventilator support and hospital days.

A patient has a PaO2 of 50 mm Hg and a PaCO2 of 42 mm Hg because of an intrapulmonary shunt. Which therapy is the patient most likely to respond best to? a. Positive pressure ventilation b. Oxygen administration at a FIO2 of 100% c. Administration of O2 per nasal cannula at 1 to 3 L/min d. Clearance of airway secretions with coughing and suctioning

a. Patients with a shunt are usually more hypoxemic than patients with a V/Q mismatch because the alveoli are filled with fluid, which prevents gas exchange. Hypoxemia resulting from an intrapulmonary shunt is usually not responsive to high O2 concentrations and the patient will usually require positive pressure ventilation. Hypoxemia associated with a V/Q mismatch usually responds favorably to O2 administration at 1 to 3 L/min by nasal cannula. Removal of secretions with coughing and suctioning is generally not effective in reversing an acute hypoxemia resulting from a shunt.

When mechanical ventilation is used for the patient with ARDS, what is the rationale for applying positive end-expiratory pressure (PEEP)? a. Prevent alveolar collapse and open up collapsed alveoli b. Permit smaller tidal volumes with permissive hypercapnia c. Promote complete emptying of the lungs during exhalation d. Permit extracorporeal oxygenation and carbon dioxide removal outside the body

a. Positive end-expiratory pressure (PEEP) used with mechanical ventilation applies positive pressure to the airway and lungs at the end of exhalation, keeping the lung partially expanded and preventing collapse of the alveoli and helping to open up collapsed alveoli. Permissive hypercapnia is allowed when the patient with ARDS is ventilated with smaller tidal volumes to prevent barotrauma. Extracorporeal membrane oxygenation and extracorporeal CO2 removal involve passing blood across a gas-exchanging membrane outside the body and then returning oxygenated blood to the body.

In caring for the patient with ARDS, what is the most characteristic sign the nurse would expect the patient to exhibit? a. Refractory hypoxemia b. Bronchial breath sounds c. Progressive hypercapnia d. Increased pulmonary artery wedge pressure (PAWP)

a. Refractory hypoxemia, hypoxemia that does not respond to increasing concentrations of oxygenation by any route, is a hallmark of ARDS and is always present. Bronchial breath sounds may be associated with the progression of ARDS. PaCO2 levels may be normal until the patient is no longer able to compensate in response to the hypoxemia. Pulmonary artery wedge pressure (PAWP) that is normally elevated in cardiogenic pulmonary edema is normal in the pulmonary edema of ARDS.

A patient with a massive hemothorax and pneumothorax has absent breath sounds in the right lung. To promote improved V/Q matching, how should the nurse position the patient? a. On the left side b. On the right side c. In a reclining chair bed d. Supine with the head of the bed elevated

a. When there is impaired function of one lung, the patient should be positioned with the unaffected lung in the dependent position to promote perfusion to the functioning tissue. If the diseased lung is positioned dependently, more V/Q mismatch would occur. The head of the bed may be elevated or a reclining chair may be used, with the patient positioned on the unaffected side, to maximize thoracic expansion if the patient has increased work of breathing.

The best patient response to treatment of ARDS occurs when initial management includes what? a. Treatment of the underlying condition b. Administration of prophylactic antibiotics c. Treatment with diuretics and mild fluid restriction d. Endotracheal intubation and mechanical ventilation

a. Because ARDS is precipitated by a physiologic insult, a critical factor in its prevention and early management is treatment of the underlying condition. Prophylactic antibiotics, treatment with diuretics and fluid restriction, and mechanical ventilation are also used as ARDS progresses.

3. The most common early clinical manifestations of ARDS that the nurse may see are a. dyspnea and tachypnea. b. cyanosis and apprehension. c. respiratory distress and frothy sputum. d. bradycardia and increased work of breathing

a. dyspnea and tachypnea.

Which descriptions are characteristic of hypoxemic respiratory failure (select all that apply)? a. Referred to as ventilatory failure b. Primary problem is inadequate O2 transfer c. Risk of inadequate O2 saturation of hemoglobin exists d. Body is unable to compensate for acidemia of increased PaCO2 e. Most often caused by ventilation-perfusion (V/Q) mismatch and shunt f. Exists when PaO2 is 60 mm Hg or less, even when O2 is administered at 60%

b, c, e, f. Hypoxemic respiratory failure is often caused by ventilation-perfusion (V/Q) mismatch and shunt. It is called oxygenation failure because the primary problem is inadequate oxygen transfer. There is a risk of inadequate oxygen saturation of hemoglobin and it exists when PaO2 is 60 mm Hg or less, even when oxygen is administered at 60%. Ventilatory failure is hypercapnic respiratory failure. Hypercapnic respiratory failure results from an imbalance between ventilatory supply and ventilatory demand and the body is unable to compensate for the acidemia of increased PaCO2

Which physiologic mechanism of hypoxemia occurs with pulmonary fibrosis? a. Anatomic shunt b. Diffusion limitation c. Intrapulmonary shunt d. V/Q mismatch ratio of less than 1

b. Diffusion limitation in pulmonary fibrosis is caused by thickened alveolar-capillary interface, which slows gas transport.

A patient in hypercapnic respiratory failure has a nursing diagnosis of ineffective airway clearance related to increasing exhaustion. What is an appropriate nursing intervention for this patient? a. Inserting an oral airway b. Performing augmented coughing c. Teaching the patient huff coughing d. Teaching the patient slow pursed lip breathing

b. Augmented coughing is done by applying pressure on the abdominal muscles at the beginning of expiration. This type of coughing helps to increase abdominal pressure and expiratory flow to assist the cough to remove secretions in the patient who is exhausted. An oral airway is used only if there is a possibility that the tongue will obstruct the airway. Huff coughing prevents the glottis from closing during the cough and works well for patients with chronic obstructive pulmonary disease (COPD) to clear central airways. Slow pursed lip breathing allows more time for expiration and prevents small bronchioles from collapsing.

Which patient with the following manifestations is most likely to develop hypercapnic respiratory failure? a. Rapid, deep respirations in response to pneumonia b. Slow, shallow respirations as a result of sedative overdose c. Large airway resistance as a result of severe bronchospasm d. Poorly ventilated areas of the lung caused by pulmonary edema

b. Hypercapnic respiratory failure is associated with alveolar hypoventilation with increases in alveolar and arterial carbon dioxide (CO2) and often is caused by problems outside the lungs. A patient with slow, shallow respirations is not exchanging enough gas volume to eliminate CO2 . Deep, rapid respirations reflect hyperventilation and often accompany lung problems that cause hypoxemic respiratory failure. Pulmonary edema and large airway resistance cause obstruction of oxygenation and result in a V/Q mismatch or shunt typical of hypoxemic respiratory failure.

The nurse suspects that a patient with PEEP is experiencing negative effects of this ventilatory maneuver when which of the following is assessed? a. Increasing PaO2 b. Decreasing blood pressure c. Decreasing heart rate (HR) d. Increasing central venous pressure (CVP)

b. PEEP increases intrathoracic and intrapulmonic pressures, compresses the pulmonary capillary bed, and reduces blood return to both the right and left sides of the heart. Increased PaO2 is an expected effect of PEEP. Preload (CVP) and cardiac output (CO) are decreased, often with a dramatic decrease in BP.

A patient with ARDS has a nursing diagnosis of risk for infection. To detect the presence of infections commonly associated with ARDS, what should the nurse monitor? a. Gastric aspirate for pH and blood b. Quality, quantity, and consistency of sputum c. Subcutaneous emphysema of the face, neck, and chest d. Mucous membranes of the oral cavity for open lesions

b. Ventilator-associated pneumonia (VAP) is one of the most common complications of ARDS. Early detection requires frequent monitoring of sputum smears and cultures and assessment of the quality, quantity, and consistency of sputum. Prevention of VAP is done with strict infection control measures, ventilator bundle protocol, and subglottal secretion drainage. Blood in gastric aspirate may indicate a stress ulcer and subcutaneous emphysema of the face, neck, and chest occurs with barotrauma during mechanical ventilation. Oral infections may result from prophylactic antibiotics and impaired host defenses but are not common.

4. Interventions used in managing the patient with ARDS include (select all that apply) a. IV injection of surfactant. b. aggressive IV fluid resuscitation. c. giving adequate analgesia and sedation. d. elevating the head of bed 30 to 45 degrees when supine. e. monitoring hemodynamic parameters and daily weights

c, d, e

The patient is being admitted to the intensive care unit (ICU) with hypercapnic respiratory failure. Which manifestations should the nurse expect to assess in the patient (select all that apply)? a. Cyanosis b. Metabolic acidosis c. Morning headache d. Respiratory acidosis e. Use of tripod position f. Rapid, shallow respirations

c, d, e, f. Morning headache, respiratory acidosis, the use of tripod position, and rapid, shallow respirations would be expected. The other manifestations are characteristic of hypoxemic respiratory failure.

When explaining respiratory failure to the patient's family, what should the nurse use as an accurate description? a. The absence of ventilation b. Any episode in which part of the airway is obstructed c. Inadequate gas exchange to meet the metabolic needs of the body d. An episode of acute hypoxemia caused by a pulmonary dysfunctio

c. Respiratory failure results when the transfer of oxygen or carbon dioxide function of the respiratory system is impaired and, although the definition is determined by PaO2 and PaCO2 levels, the major factor in respiratory failure is inadequate gas exchange to meet tissue oxygen (O2) needs. Absence of ventilation is respiratory arrest and partial airway obstruction may not necessarily cause respiratory failure. Acute hypoxemia may be caused by factors other than pulmonary dysfunction

When the V/Q lung scan result returns with a mismatch ratio that is greater than 1, which condition should be suspected? a. Pain b. Atelectasis c. Pulmonary embolus d. Ventricular septal defect

c. There will be more ventilation than perfusion (V/Q ratio greater than 1) with a pulmonary embolus. Pain and atelectasis will cause a V/Q ratio less than 1. A ventricular septal defect causes an anatomic shunt as the blood bypasses the lungs.

The nurse suspects the early stage of ARDS in any seriously ill patient who manifests what? a. Develops respiratory acidosis b. Has diffuse crackles and rhonchi c. Exhibits dyspnea and restlessness d. Has a decreased PaO2 and an increased PaCO2

c. Early signs of ARDS are insidious and difficult to detect but the nurse should be alert for any early signs of hypoxemia, such as dyspnea, restlessness, tachypnea, cough, and decreased mentation, in patients at risk for ARDS.Abnormal findings on physical examination or diagnostic studies, such as adventitious lung sounds, signs of respiratory distress, respiratory alkalosis, or decreasing PaO2, are usually indications that ARDS has progressed beyond the initial stages.

The patient with a history of heart failure and acute respiratory failure has thick secretions that she is having difficulty coughing up. Which intervention would best help to mobilize her secretions? a. Administer more IV fluid b. Perform postural drainage c. Provide O2 by aerosol mask d. Suction airways nasopharyngeally

c. For the patient with a history of heart failure, current acute respiratory failure, and thick secretions, the best intervention is to liquefy the secretions with either aerosol mask or using normal saline administered by a nebulizer. Excess IV fluid may cause cardiovascular distress and the patient probably would not tolerate postural drainage with her history. Suctioning thick secretions without thinning them is difficult and increases the patient's difficulty in maintaining oxygenation. With copious secretions, this could be done after thinning the secretions.

In patients with ARDS who survive the acute phase of lung injury, what manifestations are seen when they progress to the fibrotic phase? a. Chronic pulmonary edema and atelectasis b. Resolution of edema and healing of lung tissue c. Continued hypoxemia because of diffusion limitation d. Increased lung compliance caused by the breakdown of fibrotic tissue

c. In the fibrotic phase of ARDS, diffuse scarring and fibrosis of the lungs occur, resulting in decreased surface area for gas exchange and continued hypoxemia caused by diffusion limitation. Although edema is resolved, lung compliance is decreased because of interstitial fibrosis. Long-term mechanical ventilation is required. The patient has a poor prognosis for survival.

When teaching the patient about what was happening when experiencing an intrapulmonary shunt, which explanation is accurate? a. This occurs when an obstruction impairs the flow of blood to the ventilated areas of the lung. b. This occurs when blood passes through an anatomic channel in the heart and bypasses the lungs. c. This occurs when blood flows through the capillaries in the lungs without participating in gas exchange. d. Gas exchange across the alveolar capillary interface is compromised by thickened or damaged alveolar membranes.

c. Intrapulmonary shunt occurs when blood flows through the capillaries in the lungs without participating in gas exchange (e.g., acute respiratory distress syndrome [ARDS], pneumonia). Obstruction impairs the flow of blood to the ventilated areas of the lung in a V/Q mismatch ratio greater than 1 (e.g., pulmonary embolus). Blood passes through an anatomic channel in the heart and bypasses the lungs with anatomic shunt (e.g., ventricular septal defect). Gas exchange across the alveolar capillary interface is compromised by thickened or damaged alveolar membranes in diffusion limitation (e.g., pulmonary fibrosis, ARDS).

5. Which intervention is most likely to prevent or limit volutrauma in the patient with ARDS who is mechanically ventilated? a. Increasing PEEP b. Increasing the inspiratory flow rate c. Use of low tidal volume ventilation d. Suctioning the patient via endotracheal tube hourly

c. Use of low tidal volume ventilation

Which arterial blood gas (ABG) results would most likely indicate acute respiratory failure in a patient with chronic lung disease? a. PaO2 52 mm Hg, PaCO2 56 mm Hg pH 7.4 c. PaO2 48 mm Hg, PaCO2 54 mm Hg pH 7.38 b. PaO2 46 mm Hg, PaCO2 52 mm Hg, pH 7.36 d. PaO2 50 mm Hg, PaCO2 54 mm Hg, pH 7.28

d. In a patient with normal lung function, respiratory failure is commonly defined as a PaO2 ≤60 mm Hg or a PaCO2>45 mm Hg or both. However, because the patient with chronic pulmonary disease normally maintains low PaO2 and high PaCO2, acute respiratory failure in these patients can be defined as an acute decrease in PaO2 or an increase in PaCO2 from the patient's baseline parameters, accompanied by an acidic pH. The pH of 7.28 reflects an acidemia and a loss of compensation in the patient with chronic lung disease.

What is the primary reason that hemodynamic monitoring is instituted in severe respiratory failure? a. To detect V/Q mismatches b. To continuously measure the arterial BP c. To evaluate oxygenation and ventilation status d. To evaluate cardiac status and blood flow to tissues

d. Hemodynamic monitoring with a pulmonary artery catheter is instituted in severe respiratory failure to determine the amount of blood flow to tissues and the response of the lungs and heart to hypoxemia. Continuous BP monitoring may be performed but BP is a reflection of cardiac activity, which can be determined by the pulmonary artery catheter findings. Arterial blood gases (ABGs) are important to evaluate oxygenation and ventilation status and V/Q mismatches.

In caring for a patient in acute respiratory failure, the nurse recognizes that noninvasive positive pressure ventilation (NIPPV) may be indicated for which patient? a. Is comatose and has high oxygen requirements b. Has copious secretions that require frequent suctioning c. Responds to hourly bronchodilator nebulization treatments d. Is alert and cooperative but has increasing respiratory exhaustion

d. Noninvasive positive pressure ventilation (NIPPV) involves the application of a face mask and delivery of a volume of air under inspiratory pressure. Because the device is worn externally, the patient must be able to cooperate in its use and frequent access to the airway for suctioning or inhaled medications must not be necessary. It is not indicated when high levels of oxygen are needed or respirations are absent.

The nurse assesses that a patient in respiratory distress is developing respiratory fatigue and the risk of respiratory arrest when the patient displays which behavior? a. Cannot breathe unless he is sitting upright b. Uses the abdominal muscles during expiration c. Has an increased inspiratory-expiratory (I/E) ratio d. Has a change in respiratory rate from rapid to slow

d. The increase in respiratory rate required to blow off accumulated CO2 predisposes to respiratory muscle fatigue. The slowing of a rapid rate in a patient in acute distress indicates tiring and the possibility of respiratory arrest unless ventilatory assistance is provided. A decreased inspiratory-expiratory (I/E) ratio, orthopnea, and accessory muscle use are common findings in respiratory distress but do not necessarily signal respiratory fatigue or arrest.

Prone positioning is considered for a patient with ARDS who has not responded to other measures to increase PaO2. The nurse knows that this strategy will a. increase the mobilization of pulmonary secretions. b. decrease the workload of the diaphragm and intercostal muscles. c. promote opening of atelectatic alveoli in the upper portion of the lung. d. promote perfusion of nonatelectatic alveoli in the anterior portion of the lung.

d. When a patient with ARDS is supine, alveoli in the posterior areas of the lung are dependent and fluid-filled and the heart and mediastinal contents place more pressure on the lungs, predisposing to atelectasis. If the patient is turned prone, air-filled nonatelectatic alveoli in the anterior portion of the lung receive more blood and perfusion may be better matched to ventilation, causing less V/Q mismatch. Lateral rotation therapy is used to stimulate postural drainage and help mobilize pulmonary secretions.

2. An important consideration in selecting an O2 delivery device for the patient with acute hypoxemic respiratory failure is to a. always start with noninvasive positive pressure ventilation. b. apply a low-flow device, such as a nasal cannula or face mask. c. be able to correct the PaO2 to a normal level as quickly as possible. d. base the selection on the patient's condition and amount of FIO2 needed.

d. base the selection on the patient's condition and amount of FIO2 needed.