68: Respiratory Failure and Acute Respiratory Distress Syndrome

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

*

MULTIPLE RESPONSE 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

11. 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.

* a

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. 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.

* a

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) 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

* a

12. 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.

* c

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 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.

*ANSWER A

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

*ANSWER A

6. 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%.

*ANSWER A

10. 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."

*ANSWER B

4. 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.

*ANSWER B

1. 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

*ANSWER C

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

*ANSWER C

A patient has acute respiratory distress syndrome (ARDS) as a result of sepsis. Which measure most likely would be implemented to maintain cardiac output? 1 Administer crystalloid fluids or colloid solutions. 2 Position the patient in the Trendelenburg position. 3 Place the patient on fluid restriction and administer diuretics. 4 Perform chest physiotherapy and assist with staged coughing.

1 Administer crystalloid fluids or colloid solutions. Low cardiac output may necessitate crystalloid fluids or colloid solutions in addition to lowering positive end-expiratory pressure (PEEP) or administering inotropes. The Trendelenburg position (not recommended to treat hypotension) and chest physiotherapy are unlikely to relieve decreased cardiac output, and fluid restriction and diuresis would be inappropriate interventions.

The nurse is providing care for an older adult patient who is experiencing low partial pressure of oxygen in arterial blood (PaO2) as a result of worsening left-sided pneumonia. Which intervention should the nurse use to help the patient mobilize secretions? 1 Augmented coughing or huff coughing 2 Positioning the patient side-lying on the left side 3 Frequent and aggressive nasopharyngeal suctioning 4 Application of noninvasive positive pressure ventilation (NIPPV)

1 Augmented coughing or huff coughing Augmented coughing and huff coughing techniques may aid the patient in the mobilization of secretions. If positioned side-lying, the patient should be positioned on the right side (good lung down) for improved perfusion and ventilation. Suctioning may be indicated but always should be performed cautiously because of the risk of hypoxia. NIPPV is inappropriate in the treatment of patients with excessive secretions.

The nurse is caring for a patient receiving mechanical ventilation with high levels of positive end-expiratory pressure (PEEP). What complication should the nurse monitor for in this patient? 1 Barotrauma 2 Oxygen toxicity 3 Pneumoperitoneum 4 Ventilator-associated pneumonia (VAP)

1 Barotrauma A high level of positive end-expiratory pressure (PEEP) leads to barotrauma due to the extreme inspiratory pressure. A patient is at risk for oxygen toxicity when there are respiratory complications caused by oxygen overdose. Pneumoperitoneum is a gastrointestinal complication. Prolonged mechanical ventilation also causes respiratory complication, such as ventilator-associated pneumonia (VAP).

Which medication helps to decrease heart rate and improve cardiac output in the patient with respiratory failure and atrial fibrillation? 1 Diltiazem 2 Nitroglycerin 3 Metaproterenol 4 Methylprednisolone

1 Diltiazem Diltiazem is a calcium channel blocker and potent vasodilator. It increases the blood flow through the arteries and decreases the heart rate. Calcium channel blockers reduce blood pressure and increase cardiac output. Administration of nitroglycerin decreases pulmonary congestion caused by heart failure. Metaproterenol is a bronchodilator. It improves breathing by relaxing the muscles in the airways. Methylprednisolone is administered in conjunction with bronchodilators to treat bronchospasm and asthma.

What are the clinical manifestations of respiratory failure associated with hypoxemia? Select all that apply. 1 Fatigue 2 Confusion 3 Restlessness 4 Muscle weakness 5 Morning headache

1 Fatigue 2 Confusion 3 Restlessness Hypoxemia refers to the decrease in arterial oxygen and may manifest as fatigue, confusion, and restlessness. In hypercapnic respiratory failure, the neuromuscular conditions are affected, resulting in muscle weakness or paralysis. The patient experiences deep tendon reflexes and tremors, as well as seizures at a later stage. Hypercapnia also causes cerebral vasodilation, increased cerebral blood flow, and a mild increase in intracranial pressure that produces a headache.

Which statement describes anatomic pulmonary shunt? 1 It occurs when there is a mismatch of ventilation to perfusion. 2 It occurs when the partial pressure of oxygen falls sufficiently. 3 It occurs when ventilatory demand exceeds ventilatory supply. 4 It occurs when gas exchange across the alveolar-capillary interface is compromised.

1 It occurs when there is a mismatch of ventilation to perfusion. Pulmonary shunt is an extreme ventilation to perfusion (V/Q) mismatch, such as when parts of the lungs are perfused with blood but not ventilated with air. Hypoxia occurs when the partial pressure of oxygen (PaO2) falls sufficiently to cause signs and symptoms of inadequate oxygenation. In cases of hypercapnia, the ventilatory demand exceeds ventilatory supply and PaCO2 cannot be sustained within normal limits. During diffusion limitation, there is gas exchange across the alveolar-capillary interface. The gas exchange is compromised by a process that thickens, damages, or destroys the alveolar membrane or affects blood flow through the pulmonary capillaries.

The health care provider has prescribed a corticosteroid for a patient with acute asthma. What nursing actions are appropriate during and after administration of this medication? 1 Monitor potassium levels 2 Monitor for cardiac ischemia 3 Observe for anxiety and restlessness 4 Administer via inhalation for fast results

1 Monitor potassium levels Potassium levels of patients on corticosteroids should always be monitored because corticosteroid administration can worsen hypokalemia caused by usage of diuretics. When consumed by inhalation, corticosteriods require at least four to five days for optimum therapeutic effects. However, when administered intravenously in cases of acute asthma, corticosteriods speed up the resolution of airway inflammation and edema. Anxiety and restlessness result from hypoxia. Fear caused by the inability to breathe and a sense of loss of control, not the medication in itself, may increase anxiety. Patients being treated for bronchospasm run the risk of high cardiac ischemia with prolonged use of a beta-adrenergic drug.

A patient diagnosed with acute respiratory distress syndrome is being mechanically ventilated with 12 cm of positive end-expiratory pressure (PEEP). Upon assessment, the nurse notes deterioration of vital signs and absent breath sounds in the right lung field. What is the most likely cause for this finding? 1 Pneumothorax 2 Decreased cardiac output 3 Deterioration of the disease 4 Obstructed endotracheal tube

1 Pneumothorax A complication of PEEP may be a pneumothorax as a result of overdistention of the alveoli. If deterioration of the disease were the cause, both lung sounds would be decreased equally. Decreased cardiac output would affect vital signs, but not breath sounds. An obstructed endotracheal tube would affect both lung fields.

The nurse concludes that a patient is experiencing severe respiratory distress based on what assessment finding? 1 The patient sits in tripod position. 2 The patient reports difficulty sleeping. 3 The patient walks restlessly in the room. 4 The patient uses long sentences when conversing.

1 The patient sits in tripod position. A patient with severe respiratory distress most commonly uses the tripod position to help decrease the work of breathing and reduces respiratory distress. The patient with severe respiratory distress has severe dyspnea; therefore, the patient would only be able to speak two to three words. The patient with severe respiratory distress would experience shortness of breath and may not be able to walk. Difficulty in sleeping can have many causes and does not necessarily indicate respiratory distress.

What results in surfactant dysfunction during the injury phase of acute respiratory distress syndrome (ARDS)? 1 Decrease in gas exchange capability 2 Damage to alveolar type I and II cells 3 Engorgement of the peribronchial space 4 Ventilation to perfusion (V/Q) mismatch

2 Damage to alveolar type I and II cells During the injury phase of acute respiratory distress syndrome (ARDS), the alveolar type I and II cells (which produce surfactant) will be damaged. Along with accumulation of fluid and proteins, this cell damage results in surfactant dysfunction. The hyaline membranes that line the alveoli lead to the decrease in gas exchange capability. An engorgement of the peribronchial and perivascular interstitial space results in interstitial edema. Ventilation to perfusion (V/Q) mismatch results in hypoxemia.

What is included in the subjective data the nurse obtains after the diagnosis of a patient with respiratory failure? 1 Vital signs 2 Health history 3 Neurologic findings 4 Diagnostic test results

2 Health history The nursing diagnosis for a patient includes subjective and objective data. Subjective data are inclusive of health information like health history, medications, surgery, or other treatments. Vital signs are objective rather than subjective data. Diagnostic tests are performed prior to a diagnosis. A neurologic examination assesses for any slurred speech, restlessness, or delirium.

A patient has developed acute respiratory distress syndrome (ARDS) in the intensive care unit. What nursing action will assist in the treatment of this disorder? 1 Effective coughing 2 Positioning strategy 3 Chest physiotherapy 4 Hydration and humidification

2 Positioning strategy Positioning strategy during oxygenation has helped patients with acute respiratory distress syndrome (ARDS) show significant improvement. Effective coughing and adequate hydration and humidification help patients mobilize secretions. Chest physiotherapy is suggested for patients with acute respiratory failure who produce sputum of more than 30 mL per day.

The nurse attending to an older adult patient hears the patient coughing. On auscultation, the nurse finds retained pulmonary secretions in the lungs. What nursing interventions should the nurse perform to mobilize secretions? Select all that apply. 1 Limit fluid intake. 2 Provide humidified air. 3 Provide chest physiotherapy. 4 Advise bed rest for the patient. 5 Encourage the patient to cough.

2 Provide humidified air 3 Provide chest physiotherapy 5 Encourage the patient to cough Retained pulmonary secretions increase the risk of respiratory failure. It is important to mobilize the secretions and clear the airway to facilitate ventilation. Effective coughing is an important measure to move up the secretions and relieve obstruction of the airway. Chest physiotherapy can be used in patients who produce a copious amount of sputum and who have a collapsed lung. Humidified air helps to keep secretions liquefied and eases in coughing them out. The patient should not be limited to bed rest; ambulation should be done when possible, because it helps to expand the lungs and clear the secretions. Fluid intake should not be restricted. Adequate fluid intake is required to prevent the secretions from thickening.

Which medication helps reduce the risk of stress ulcers in a patient with acute respiratory failure? 1 Propofol 2 Sucralfate 3 Fentanyl 4 Vancomycin

2 Sucralfate A patient with acute respiratory illness has a high risk of bleeding from stress ulcers due to decreased mucus production. Therefore administration of mucosal protective agents like sucralfate will be beneficial. Propofol is a sedative and analgesic that helps to alleviate pain. It does not help treat stress ulcers. Fentanyl is an opioid used to decrease anxiety but has no effect on the gastrointestinal tract. Vancomycin is an antibiotic used to treat bacterial infections.

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

22. 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.

The nurse is admitting a patient with asthma in acute respiratory distress. The nurse auscultates the patient's lungs and notes cessation of the inspiratory wheezing. The patient has not yet received any medication. What should this finding most likely suggest to the nurse? 1 Spontaneous resolution of the acute asthma attack 2 An acute development of bilateral pleural effusions 3 Airway constriction requiring intensive interventions 4 Overworked intercostal muscles resulting in poor air exchange

3 Airway constriction requiring intensive interventions When the patient in respiratory distress has inspiratory wheezing and then he or she ceases, it is an indication of airway obstruction. This finding requires emergency action to restore the airway. Cessation of inspiratory wheezing does not indicate spontaneous resolution of the acute asthma attack, bilateral pleural effusion development, or overworked intercostal muscles in this asthmatic patient who is in acute respiratory distress.

A patient is in the exudative phase of acute respiratory distress syndrome (ARDS). What does the nurse determine the function of surfactant will be in this phase? 1 Attract neutrophils 2 Decrease tidal volume 3 Maintain alveolar stability 4 Release cellular mediators

3 Maintain alveolar stability During the injury, or exudative phase, of ARDS, the alveolar type I and II cells produce surfactant to prevent alveolar collapse. The inflammatory and immune systems attract neutrophils to the pulmonary interstitium. A decrease in tidal volume is caused by stimulation of the juxtacapillary receptors. The neutrophils release biochemical, humoral, and cellular mediators to produce changes in the lungs.

A patient is receiving respiratory therapy for the treatment of acute respiratory failure. What are the related interventions to maximize oxygen delivery? 1 Administering IV antibiotics 2 Reducing pain, anxiety, and restlessness 3 Maintaining adequate hemoglobin concentration 4 Maintaining the caloric requirements of the body

3 Maintaining adequate hemoglobin concentration Adequate hemoglobin concentration is maintained by transfusion of packed red blood cells. The hemoglobin increases the oxygen-carrying capacity of the blood and thus supports oxygenation. Pulmonary infections are reduced by administering IV antibiotics, such as azithromycin. Sedation and analgesia, along with drug therapy, help to decrease anxiety, agitation, and pain. Nutritional therapy focuses on the maintenance of caloric requirement of patients with acute respiratory failure.

A nurse is caring for a patient diagnosed with acute respiratory distress syndrome. The nurse is aware that these patients often will require which intervention? 1 Peritoneal dialysis 2 Frequent suctioning 3 Mechanical ventilation 4 Creatinine and blood urea nitrogen (BUN) testing

3 Mechanical ventilation Patients with acute respiratory distress syndrome likely will require mechanical ventilation to support their respiratory status. Frequent suctioning is not required often, but some suctioning may be required. Peritoneal dialysis and creatinine and BUN testing might be necessary with some level of kidney failure, not respiratory compromise.

The nurse is caring for a patient who is experiencing acute respiratory distress due to accumulation of nasal secretions in the airways. What is appropriate to include in the patient's plan of care? Select all that apply. 1 Administer fentanyl. 2 Restrict fluids to 1 L daily. 3 Encourage the patient to cough. 4 Administer nebulized acetylcysteine. 5 Elevate the patient's lower limbs to 45 degrees.

3 Encourage the patient to cough. 4 Administer nebulized acetylcysteine. Coughing helps to expel the nasal secretions and clears the airways; therefore, the nurse should encourage the patient to cough. Administering nebulized acetylcysteine with a bronchodilator helps to reduce the thickness of nasal secretions and increases their elimination. The patient should be provided 2 to 3 L of fluids daily in order to reduce the thickness of nasal secretions. The nurse should elevate the patient's head by raising the bed to 45 degrees to prevent breathlessness. Elevating the lower limbs will not be helpful for the patient. Fentanyl helps to reduce pain but does not help to clear airways.

Which pathophysiologic change occurs in the fibrotic phase of acute respiratory distress syndrome (ARDS)? 1 Diseased lung is characterized by dense, fibrous tissue 2 Increased fluid accumulation and decreased lung compliance 3 Engorgement of the peribronchial and perivascular interstitial space 4 Diseased lung is completely remodeled by collagenous and fibrous tissues

4 Diseased lung is completely remodeled by collagenous and fibrous tissues The fibrotic phase is the late phase of acute respiratory distress syndrome (ARDS), which occurs two to three weeks after the lung injury. During this phase, the lung is completely remodeled by collagenous and fibrous tissues. During the reparative phase, which begins one to two weeks from the lung injury, the diseased lung appears dense with fibrous tissue, there is an increase in the fluid accumulations, and lung compliance decreases. Engorgement of the peribronchial and perivascular interstitial space occurs within 24 to 48 hours of the lung injury.

A patient with significant right-sided pneumonia is receiving respiratory therapy. Which position is best suited for this patient? 1 Prone position 2 Tripod position 3 Supine position 4 Side-lying position

4 Side-lying position A patient with a medical condition involving only one lung requires focused intervention. A lateral or side-lying position is used for patients whose condition involves only one lung, because it allows for improved ventilation to perfusion that matches with the affected lung. This position also optimizes pulmonary blood flow and ventilation to the dependent lung areas. When a patient is in the prone position, air-filled, nonatelectatic alveoli in the ventral (anterior) portion of the lung become dependent, and perfusion may be better matched to ventilation. However, not all patients respond well to prone positioning, and there is no reliable way of predicting who will respond. Tripod positioning helps to increase chest and lung expansion and decrease the effort needed to breathe for patients with chronic obstructive pulmonary disease, not patients with conditions affecting only one lung. The supine position changes the pleural pressure and predisposes the patient to atelectasis.

Bed rest is prescribed for a patient during the acute phase of respiratory failure. What is the rationale for the recommendation of bed rest and limitation of other activity in the plan of care? 1 To prevent further alveolar collapse 2 To decrease the basal metabolic rate 3 To promote the clearance of secretions 4 To reduce the cellular demand for oxygen

4 To reduce the cellular demand for oxygen To reduce the cellular demand for oxygen Respiratory failure interferes with ventilation and oxygenation. It is essential to reduce the body's need for oxygen at the cellular level. Bed rest is an essential and effective means of reducing the need for oxygen. Bed rest and limitation of activity do not prevent alveolar collapse, clear secretions, or decrease the basal metabolic rate.

The nurse suspects that a patient has a pulmonary embolus. Which clinical manifestation confirms the nurse's suspicion? 1 Tachycardia 2 Muscle weakness 3 Morning headache 4 Ventilation to perfusion (V/Q) mismatch

4 Ventilation to perfusion (V/Q) mismatch The nurse conducts a computerized scan or ventilation to perfusion V/Q lung scan to confirm pulmonary embolus. Tachycardia is an early sign of respiratory failure consequent to physiologic stress. In hypercapnic respiratory failure, muscle weakness or paralysis is caused by altered neuromuscular conditions. The patient experiences deep tendon reflexes, tremors, as well as seizures at a later stage. Hypercapnia also causes cerebral vasodilation, increased cerebral blood flow, and a mild increase in intracranial pressure that produces a headache.

Which indirect lung condition predisposes a patient to acute respiratory distress syndrome (ARDS)? 1 Sepsis 2 Aspiration 3 Pneumonia 4 Severe massive trauma

4 Severe massive trauma Severe massive trauma An indirect lung injury that predisposes a patient to ARDS is a severe massive trauma. Aspiration, pneumonia, and sepsis are all examples of direct lung injuries that can predispose a patient to ARDS.

Which drug is used to treat pulmonary infection? 1 Albuterol 2 Lorazepam 3 Nitroglycerin 4 Azithromycin

4. Azithromycin Pulmonary infections can exacerbate acute respiratory failure. An intravenous antibiotic such as azithromycin is administered to treat pulmonary infections. Albuterol is a short-acting bronchodilator that reverses the effects of bronchospasm. Lorazepam is used to decrease anxiety, agitation, and pain. Medications used in the treatment of pulmonary congestion infections include diuretics like nitroglycerin that are administered intravenously.

Physiological Integrity 8. To evaluate both oxygenation and ventilation in a patient with acute respiratory failure, the nurse uses the findings revealed with a. arterial blood gas (ABG) analysis. b. hemodynamic monitoring. c. chest x-rays. d. pulse oximetry.

A Rationale: ABG analysis is useful because it provides information about both oxygenation and ventilation and assists with determining possible etiologies and appropriate treatment. The other tests may also provide useful information about patient status but will not indicate whether the patient has hypoxemia, hypercapnia, or both. Cognitive Level: Comprehension Text Reference: p. 1805 Nursing Process: Assessment

Physiological Integrity 19. Which information obtained by the nurse when assessing a patient with acute respiratory distress syndrome (ARDS) who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP) indicates a complication of ventilator therapy is occurring? a. The patient has subcutaneous emphysema. b. The patient has a sinus bradycardia, rate 52. c. The patient's PaO2 is 50 mm Hg and the SaO2 is 88%. d. The patient has bronchial breath sounds in both the lung fields.

A Rationale: Complications of positive-pressure ventilation (PPV) and PEEP include subcutaneous emphysema. Bradycardia, hypoxemia, and bronchial breath sounds are all concerns, but they are not caused by PPV and PEEP. Cognitive Level: Application Text Reference: p. 1816 Nursing Process: Assessment

Physiological Integrity 2. The nurse will monitor for clinical manifestations of hypercapnia when a patient in the emergency department has a. chest trauma and multiple rib fractures. b. carbon monoxide poisoning after a house fire. c. left-sided ventricular failure and acute pulmonary edema. d. tachypnea and acute respiratory distress syndrome (ARDS).

A Rationale: Hypercapnia is caused by poor ventilatory effort, which occurs in chest trauma when rib fractures (or flail chest) decrease lung ventilation. Carbon monoxide poisoning, acute pulmonary edema, and ARDS are more commonly associated with hypoxemia. Cognitive Level: Application Text Reference: p. 1800 Nursing Process: Assessment

Physiological Integrity 14. When admitting a patient in possible respiratory failure with a high PaCO2, which assessment information will be of most concern to the nurse? a. The patient is somnolent. b. The patient's SpO2 is 90%. c. The patient complains of weakness. d. The patient's blood pressure is 162/94.

A 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. Cognitive Level: Application Text Reference: p. 1804 Nursing Process: Assessment

Physiological Integrity 22. A patient with acute respiratory distress syndrome (ARDS) has progressed to the fibrotic phase. The patient's family members are anxious about the patient's condition and are continuously present at the hospital. In addressing the family's concerns, it is important for the nurse to a. support the family and help them understand the realistic expectation that the patient's chance for survival is poor. b. inform the family that home health nurses will be able to help them maintain the mechanical ventilation at home after patient discharge. c. refer the family to social support services and case management to plan for transfer of the patient to a long-term care facility. d. provide hope and encouragement to the family because the patient's disease process has started to resolve.

A Rationale: The chance for survival is poor when the patient progresses to the fibrotic stage because permanent damage to the alveoli has occurred. Because of continued severe hypoxemia, the patient is not a candidate for home health or long-term care. The fibrotic stage indicates a poor patient prognosis, not the resolution of the ARDS process. Cognitive Level: Application Text Reference: p. 1814 Nursing Process: Implementation

Physiological Integrity 5. A patient is brought to the emergency department unconscious following a barbiturate overdose. Which potential complication will the nurse include when developing the plan of care? a. Hypercapnic respiratory failure related to decreased ventilatory effort b. Hypoxemic respiratory failure related to diffusion limitations c. Hypoxemic respiratory failure related to shunting of blood d. Hypercapnic respiratory failure related to increased airway resistance

A Rationale: The patient with an opioid overdose develops hypercapnic respiratory failure as a result of the decrease in respiratory rate and depth. Diffusion limitations, blood shunting, and increased airway resistance are not the primary pathophysiology causing the respiratory failure. Cognitive Level: Application Text Reference: p. 1800 Nursing Process: Diagnosis

3. 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)

ANSWER B

7. 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

ANSWER B*

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.

ANSWER B*

The nurse is providing care for an older adult patient who is experiencing low partial pressure of oxygen in arterial blood (PaO2) as a result of worsening left-sided pneumonia. Which intervention should the nurse use to help the patient mobilize his secretions? A. Augmented coughing or huff coughing B. Positioning the patient side-lying on his left side C. Frequent and aggressive nasopharyngeal suctioning D. Application of noninvasive positive pressure ventilation (NIPPV)

Ans. A Augmented coughing and huff coughing techniques may aid the patient in the mobilization of secretions. If positioned side-lying, the patient should be positioned on his right side (good lung down) for improved perfusion and ventilation. Suctioning may be indicated but should always be performed cautiously because of the risk of hypoxia. NIPPV is inappropriate in the treatment of patients with excessive secretions.

The nurse in the cardiac care unit is caring for a patient who has developed acute respiratory failure. Which medication does the nurse know is being used to decrease this patient's pulmonary congestion and agitation? A. Morphine sulfate B. Albuterol (Ventolin) C. Azithromycin (Zithromax) D. Methylprednisolone (Solu-Medrol)

Ans. A For a patient with acute respiratory failure related to the heart, morphine is used to decrease pulmonary congestion as well as anxiety, agitation, and pain. Albuterol is used to reduce bronchospasm. Azithromycin is used for pulmonary infections. Methylprednisolone is used to reduce airway inflammation and edema

A patient is in acute respiratory distress syndrome (ARDS) as a result of sepsis. Which measure(s) would most likely be implemented to maintain cardiac output? A. Administer crystalloid fluids or colloid solutions. B. Position the patient in the Trendelenburg position. C. Place the patient on fluid restriction and administer diuretics. D. Perform chest physiotherapy and assist with staged coughing

Ans. A Low cardiac output may necessitate crystalloid fluids or colloid solutions in addition to lowering positive end-expiratory pressure (PEEP) or administering inotropes. The Trendelenburg position (not recommended to treat hypotension) and chest physiotherapy are unlikely to relieve decreased cardiac output, and fluid restriction and diuresis would be inappropriate interventions

The patient has pulmonary fibrosis and experiences hypoxemia during exercise but not at rest. To plan for the patient's care, the nurse should know that this patient is experiencing which physiologic mechanism of respiratory failure? A. Diffusion limitation B. Intrapulmonary shunt C. Alveolar hypoventilation D. Ventilation-perfusion mismatch

Ans. A The patient with pulmonary fibrosis has a thickened alveolar-capillary interface that slows gas transport, and hypoxemia is more likely during exercise than at rest. Intrapulmonary shunt occurs when alveoli fill with fluid (e.g., ARDS, pneumonia). Alveolar hypoventilation occurs when there is a generalized decrease in ventilation (e.g., restrictive lung disease, CNS diseases, neuromuscular diseases). Ventilation-perfusion mismatch occurs when the amount of air does not match the amount of blood that the lung receives (e.g., COPD, pulmonary embolus).

When caring for the patient with ARDS, the critical care nurse knows that therapy is appropriate for the patient when which goal is being met? A. pH is 7.32. B. PaO2 is greater than or equal to 60 mm Hg. C. PEEP increased to 20 cm H2O caused BP to fall to 80/40. D. No change in PaO2 when patient is turned from supine to prone position

Ans. B The overall goal in caring for the patient with ARDS is for the PaO2 to be greater than or equal to 60mm Hg with adequate lung ventilation to maintain a normal pH of 7.35 to 7.45. PEEP is usually increased for ARDS patients, but a dramatic reduction in BP indicates a complication of decreased cardiac output. A positive occurrence is a marked improvement in PaO2 from perfusion better matching ventilation when the anterior air-filled, nonatelectatic alveoli become dependent in the prone position

The nurse is aware of the value of using a mini-tracheostomy to facilitate suctioning when patients are unable to independently mobilize their secretions. For which patient is the use of a mini-trach indicated? A. A patient whose recent ischemic stroke has resulted in the loss of his gag reflex B. A patient who requires long-term mechanical ventilation as the result of a spinal cord injury C. A patient whose increased secretions are the result of community-acquired pneumonia D. A patient with a head injury who has developed aspiration pneumonia after his family insisted on spoon-feeding him

Ans. C It is appropriate to suction a patient with pneumonia using a mini-trach if blind suctioning is ineffective or difficult. An absent or compromised gag reflex, long-term mechanical ventilation, and a history of aspiration contraindicates the use of a mini-trach

The nurse is caring for a patient who is admitted with a barbiturate overdose. The patient is comatose with BP 90/60, apical pulse 110, and respiratory rate 8. Based upon the initial assessment findings, the nurse recognizes that the patient is at risk for which type of respiratory failure? A. Hypoxemic respiratory failure related to shunting of blood B. Hypoxemic respiratory failure related to diffusion limitation C. Hypercapnic respiratory failure related to alveolar hypoventilation D. Hypercapnic respiratory failure related to increased airway resistance

Ans. C The patient's respiratory rate is decreased as a result of barbiturate overdose, which caused respiratory depression. The patient is at risk for hypercapnic respiratory failure resulting from the decreased respiratory rate and thus decreased CO2 elimination. Barbiturate overdose does not lead to shunting of blood, diffusion limitations, or increased airway resistance.

The nurse is admitting a 45-year-old asthmatic patient in acute respiratory distress. The nurse auscultates the patient's lungs and notes cessation of the inspiratory wheezing. The patient has not yet received any medication. What should this finding most likely suggest to the nurse? A. Spontaneous resolution of the acute asthma attack B. An acute development of bilateral pleural effusions C. Airway constriction requiring intensive interventions D. Overworked intercostal muscles resulting in poor air exchange

Ans. C When the patient in respiratory distress has inspiratory wheezing, and then it ceases, it is an indication of airway obstruction. This finding requires emergency action to restore the airway. Cessation of inspiratory wheezing does not indicate spontaneous resolution of the acute asthma attack, bilateral pleural effusion development, or overworked intercostal muscles in this asthmatic patient that is in acute respiratory distress

When the nurse is explaining treatment to the families, for which patient would NIPPV be an appropriate intervention to promote oxygenation? A. A patient whose cardiac output and blood pressure are unstable B. A patient whose respiratory failure is due to a head injury with loss of consciousness C. A patient with a diagnosis of cystic fibrosis and who is currently producing copious secretions D. A patient who is experiencing respiratory failure as a result of the progression of myasthenia gravis

Ans. D NIPPV is most effective in treating patients with respiratory failure resulting from chest wall and neuromuscular disease. It is not recommended in patients who are experiencing hemodynamic instability, decreased level of consciousness, or excessive secretions.

Physiological Integrity 9. A finding indicating to the nurse that a 22-year-old patient with respiratory distress is in acute respiratory failure includes a a. shallow breathing pattern. b. partial pressure of arterial oxygen (PaO2) of 45 mm Hg. c. partial pressure of carbon dioxide in arterial gas (PaCO2) of 34 mm Hg. d. respiratory rate of 32/min.

B Rationale: The PaO2 indicates severe hypoxemia and that the nurse should take immediate action to correct this problem. Shallow breathing, rapid respiratory rate, and low PaCO2 can be caused by other factors, such as anxiety or pain. Cognitive Level: Application Text Reference: p. 1806 Nursing Process: Assessment

Physiological Integrity 13. When the nurse is caring for an obese patient with left lower-lobe pneumonia, gas exchange will be best when the patient is positioned a. on the left side. b. on the right side. c. in the high-Fowler's position. d. in the tripod position.

B 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. Cognitive Level: Comprehension Text Reference: pp. 1809-1810 Nursing Process: Implementation

Psychosocial Integrity 23. 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? a. Notify the health care provider of the patient's vital signs. b. Obtain oxygen saturation using pulse oximetry. c. Document the vital signs and continue to monitor. d. Administer PRN acetaminophen (Tylenol) 650 mg.

B 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. Documentation and continued monitoring of the vital signs are needed but do not constitute an adequate response to the patient situation. Tylenol administration is appropriate but not the highest priority for this patient. Cognitive Level: Application Text Reference: pp. 1813-1814 Nursing Process: Implementation

Physiological Integrity 11. A patient with hypercapnic respiratory failure has a respiratory rate of 8 and an SpO2 of 89%. The patient is increasingly lethargic. Which collaborative 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 bilevel positive pressure ventilation (BiPAP)

B 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. Cognitive Level: Application Text Reference: pp. 1807-1808, 1810 Nursing Process: Planning

Physiological Integrity 24. Which of these nursing actions included in the care of a mechanically ventilated patient with acute respiratory distress syndrome (ARDS) is most appropriate for the RN to delegate to an experienced LPN/LVN working in the intensive care unit? a. Placing the patient in the prone position b. Assessment of patient breath sounds c. Administration of enteral tube feedings d. Obtaining the pulmonary artery pressures

C Rationale: Administration of tube feedings 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. Cognitive Level: Application Text Reference: pp. 1816-1818 Nursing Process: Implementation

Physiological Integrity 17. All the following medications are ordered for a mechanically ventilated patient with acute respiratory distress syndrome (ARDS) and acute renal failure. Which medication should the nurse discuss with the health care provider before administration? a. IV ranitidine (Zantac) 50 mg IV b. sucralfate (Carafate) 1 g per nasogastric tube c. IV gentamicin (Garamycin) 60 mg d. IV methylprednisolone (Solu-Medrol) 40 mg

C 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. Cognitive Level: Application Text Reference: p. 1816 Nursing Process: Implementation

1. It will be most important for the nurse to check pulse oximetry for which of these patients? a. A patient with emphysema and a respiratory rate of 16 b. A patient with massive obesity who is refusing to get out of bed c. A patient with pneumonia who has just been admitted to the unit d. A patient who has just received morphine sulfate for postoperative pain

C Rationale: Hypoxemia and hypoxemic respiratory failure are caused by disorders that interfere with the transfer of oxygen into the blood, such as pneumonia. The other listed disorders are more likely to cause problems with hypercapnia because of ventilatory failure. Cognitive Level: Application Text Reference: pp. 1799-1800 Nursing Process: Assessment

Physiological Integrity 3. When a patient is diagnosed with pulmonary fibrosis, the nurse will teach the patient about the risk for poor oxygenation because of a. too-rapid movement of blood flow through the pulmonary blood vessels. b. incomplete filling of the alveoli with air because of reduced respiratory ability. c. decreased transfer of oxygen into the blood because of thickening of the alveoli. d. mismatch between lung ventilation and blood flow through the blood vessels of the lung.

C Rationale: Pulmonary fibrosis causes the alveolar-capillary interface to become thicker, which increases the amount of time it takes for gas to diffuse across the membrane. Too-rapid pulmonary blood flow is another cause of shunt but does not describe the pathology of pulmonary fibrosis. Decrease in alveolar ventilation will cause hypercapnia. Ventilation and perfusion are matched in pulmonary fibrosis; the problem is with diffusion. Cognitive Level: Application Text Reference: p. 1802 Nursing Process: Implementation

Physiological Integrity 16. When caring for a patient who developed acute respiratory distress syndrome (ARDS) as a result of a urinary tract infection (UTI), the nurse is asked by the patient's family how a urinary tract infection could cause lung damage. Which response by the nurse is appropriate? a. "The infection spread through the circulation from the urinary tract to the lungs." b. "The urinary tract infection produced toxins that damaged the lungs." c. "The infection caused generalized inflammation that damaged the lungs." d. "The fever associated with the infection led to scar tissue formation in the lungs."

C Rationale: The pathophysiologic changes that occur in ARDS are thought to be caused by inflammatory and immune reactions that lead to changes at the alveolar-capillary membrane. ARDS is not directly caused by infection, toxins, or fever. Cognitive Level: Application Text Reference: p. 1813 Nursing Process: Implementation

Physiological Integrity 21. 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? a. The skin on the patient's back is intact and without redness. b. Sputum and blood cultures show no growth after 24 hours. c. The patient's PaO2 is 90 mm Hg, and the SaO2 is 92%. d. Endotracheal suctioning results in minimal mucous return.

C 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. Cognitive Level: Application Text Reference: pp. 1817-1818 Nursing Process: Evaluation

The nurse is caring for a patient brought to the hospital with complaints of vomiting with suspected respiratory failure caused by sepsis. What early clinical manifestation of the condition does the nurse document? Select all that apply. 1 Organ dysfunction 2 White-out chest x-ray 3 Cough and restlessness 4 Dyspnea and tachypnea 5 Normal chest auscultation

Correct3 Cough and restlessness Correct4 Dyspnea and tachypnea Correct5 Normal chest auscultation Early clinical manifestations of acute respiratory distress syndrome (ARDS) usually appear within 24 to 48 hours after a lung injury. The patient may cough and feel restless and exhibit signs of dyspnea and tachypnea. Chest auscultation usually reveals normal crackling or rhonchi breathing sounds. Organ dysfunction may develop later if therapy is not promptly started. In the advanced stage of ARDS, the chest x-ray is white-out and shows empty air spaces.

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. 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.

D

20. 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.

D

Physiological Integrity 7. A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department complaining of acute respiratory distress. When monitoring the patient, which assessment by the nurse will be of most concern? a. The patient is sitting in the tripod position. b. The patient has bibasilar lung crackles. c. The patient's pulse oximetry indicates an O2 saturation of 91%. d. The patient's respiratory rate has decreased from 30 to 10/min.

D 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, the nurse will need to take immediate action. 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. Cognitive Level: Application Text Reference: p. 1804 Nursing Process: Assessment

Physiological Integrity 4. A patient is diagnosed with a large pulmonary embolism. When explaining to the patient what has happened to cause respiratory failure, which information will the nurse include? a. "Oxygen transfer into your blood is slow because of thick membranes between the small air sacs and the lung circulation." b. "Thick secretions in your small airways are blocking air from moving into the small air sacs in your lungs." c. "Large areas of your lungs are getting good blood flow but are not receiving enough air to fill the small air sacs." d. "Blood flow though some areas of your lungs is decreased even though you are taking adequate breaths."

D Rationale: A pulmonary embolus limits blood flow but does not affect ventilation, leading to a ventilation-perfusion mismatch. The response beginning, "Oxygen transfer into your blood is slow because of thick membranes" describes a diffusion problem. The remaining two responses describe ventilation-perfusion mismatch with adequate blood flow but poor ventilation. Cognitive Level: Application Text Reference: p. 1802 Nursing Process: Implementation

Physiological Integrity 20. 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? a. "PEEP will prevent fibrosis of the lung from occurring." b. "PEEP will push more air into the lungs during inhalation." c. "PEEP allows the ventilator to deliver 100% oxygen to the lungs." d. "PEEP prevents the lung air sacs from collapsing during exhalation."

D Rationale: By preventing alveolar collapse during expiration, PEEP improves gas exchange and oxygenation. PEEP will not prevent the fibrotic changes that occur with ARDS, push more air into the lungs, or change the fraction of inspired oxygen (FIO2) delivered to the patient. Cognitive Level: Comprehension Text Reference: p. 1817 Nursing Process: Planning

Physiological Integrity 10. While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient's arterial oxyhemoglobin saturation (SpO2) from 94% to 88%. The nurse will a. assist the patient to cough and deep-breathe. b. help the patient to sit in a more upright position. c. suction the patient's oropharynx. d. increase the oxygen flow rate.

D Rationale: 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. Cognitive Level: Application Text Reference: pp. 1802, 1807 Nursing Process: Implementation

Physiological Integrity 18. After prolonged cardiopulmonary bypass, a patient develops increasing shortness of breath and hypoxemia. 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 a. positioning the patient for a chest radiograph. b. drawing blood for arterial blood gases. c. obtaining a ventilation-perfusion scan. d. inserting a pulmonary artery catheter.

D Rationale: Pulmonary artery wedge pressure will remain at normal levels 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. Cognitive Level: Application Text Reference: p. 1815 Nursing Process: Implementation

Physiological Integrity 6. 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? a. Monitor the patient every 10 to 15 minutes. b. Notify the patient's health care provider immediately. c. Attempt to calm and reassure the patient. d. Assess vital signs and pulse oximetry.

D Rationale: The nurse needs to collect additional clinical data to share with the health care provider and to start interventions quickly if appropriate (e.g., increased oxygen flow if hypoxic). The change in the patient's neurologic status may indicate deterioration in respiratory function, and the health care provider should be notified immediately but only after some additional information is obtained. Monitoring the patient and attempting to calm the patient are appropriate actions, but they will not prevent further deterioration of the patient's clinical status and may delay care. Cognitive Level: Application Text Reference: pp. 1804-1805 Nursing Process: Assessment

Physiological Integrity 12. A patient in acute respiratory failure as a complication of COPD has a PaCO2 of 65 mm Hg, rhonchi audible in the right lung, and marked fatigue with a weak cough. The nurse will plan to a. allow the patient to rest to help conserve energy. b. arrange for a humidifier to be placed in the patient's room. c. position the patient on the right side with the head of the bed elevated. d. assist the patient with augmented coughing to remove respiratory secretions.

D Rationale: The patient's assessment indicates that assisted coughing is needed to help remove secretions, which will improve PaCO2 and will also help to correct fatigue. If the patient is allowed to rest, the PaCO2 will increase. Humidification may help loosen secretions, but the weak cough effort will prevent the secretions from being cleared. The patient should be positioned with the good lung down to improve gas exchange. Cognitive Level: Application Text Reference: p. 1809 Nursing Process: Planning

Physiological Integrity 15. 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? a. The patient has a cough that is productive of blood-tinged sputum. b. The patient has scattered crackles throughout the posterior lung bases. c. The patient's temperature is 101.5° F after 2 days of IV antibiotic therapy. d. The patient's SpO2 has dropped to 90%, although the O2 flow rate has been increased.

D Rationale: The patient's dropping SpO2 despite having an increase in 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. Cognitive Level: Application Text Reference: p. 1815 Nursing Process: Assessment

19. 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.

a

23. 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%.

a

26. 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

a

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 d. Albuterol (Ventolin) b. Furosemide (Lasix) e. Ceftriaxone (Rocephin) c. Nitroglycerin (Tridil) 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.

Which changes of aging contribute to the increased risk for respiratory failure in older adults (select all that apply)? a. Alveolar dilation d. Increased infection risk b. Increased delirium e. Decreased respiratory muscle strength c. Changes in vital signs 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 c. Keeping his legs still to avoid dislodging the airway b. Monitoring for hypermetabolism 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. c. prolonged hypotension. b. oxygen toxicity. 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.

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

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

Priority Decision: 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 c. Progressive hypercapnia b. Bronchial breath sounds 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 c. In a reclining chair bed b. On the right side 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.

14. 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%.

b

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. 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

b

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

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 c. Teaching the patient huff coughing b. Performing augmented 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 physiologic mechanism of hypoxemia occurs with pulmonary fibrosis? a. Anatomic shunt c. Intrapulmonary shunt b. Diffusion limitation 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.

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 c. Decreasing heart rate (HR) b. Decreasing blood pressure 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 c. Subcutaneous emphysema of the face, neck, and chest b. Quality, quantity, and consistency of sputum 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.

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.

c

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 d. Respiratory acidosis b. Metabolic acidosis e. Use of tripod position c. Morning headache 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.

The nurse suspects the early stage of ARDS in any seriously ill patient who manifests what? a. Develops respiratory acidosis c. Exhibits dyspnea and restlessness b. Has diffuse crackles and rhonchi 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 c. Provide O2 by aerosol mask b. Perform postural drainage 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).

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 dysfunction

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 c. Pulmonary embolus b. Atelectasis 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.

15. 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).

d

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

d

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.

d

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.

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.

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 c. Has an increased inspiratory-expiratory (I/E) ratio b. Uses the abdominal muscles during expiration 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.