Ch. 15: Acute Respiratory Failure

Select the strategies for preventing deep vein thrombosis (DVT) and pulmonary embolus (PE). (Select all that apply.)

Graduated compression stockings Heparin or low-molecular weight heparin for patients at risk Sequential compression devices

The nurse assesses a patient who is admitted for an overdose of sedatives. The nurse expects to find which acid-base alteration?

Hypoventilation and respiratory acidosis

Which of the following statements is true regarding oral care for the prevention of ventilator-associated pneumonia (VAP)? (Select all that apply.)

Implementing a comprehensive oral care program is an intervention for preventing VAP Oral care protocols should include oral suctioning and brushing teeth. Protocols that include chlorhexidine gluconate have been effective in preventing VAP

Which of the following statements is true regarding venous thromboembolism (VTE) and pulmonary embolus (PE)?

PE should be suspected in any patient who has unexplained cardiorespiratory complaints and risk factors for VTE

The nurse is caring for a patient in acute respiratory failure and understands that the patient should be positioned (Select all that apply.)

high Fowler's. side lying with head of bed elevated. sitting in a chair.

A strategy for preventing pulmonary embolism in patients at risk who cannot take anticoagulants is

insertion of a vena cava filter.

The nurse is discharging a patient home following treatment for community-acquired pneumonia. As part of the discharge teaching, the nurse instructs,

"It is important for you to get an annual influenza shot to reduce your risk of pneumonia."

The nurse calculates the PaO2/FiO2 ratio for the following values: PaO2 is 78 mm Hg; FiO2 is 0.6 (60%).

130; meets criteria for ARDS 78/0.60 = 130, which meets the criteria for ARDS

The nurse is caring for a patient with cystic fibrosis (CF) and understands that treatment consists of which of the following? (Select all that apply.)

Airway clearance therapies Antibiotic therapy Nutritional support Lung transplant

Identify diagnostic criteria for ARDS. (Select all that apply.)

Bilateral infiltrates on chest x-ray study PaO2/ FiO2 ratio of less than 200

The nurse is caring for a postoperative patient with chronic obstructive pulmonary disease (COPD). Which assessment would be a cue to the patient developing postoperative pneumonia?

Change in sputum characteristics

The patient with acute respiratory distress syndrome (ARDS) would exhibit which of the following symptoms?

Decreasing PaO2 levels despite increased FiO2 administration

The nurse is caring for a mechanically ventilated patient. The nurse understands that strategies to prevent ventilator-associated pneumonia include which of the following? (Select all that apply.)

Drain condensate from the ventilator tubing away from the patient. Elevate the head of the bed 30 to 45 degrees. Perform regular oral care with chlorhexidine.

The nurse is assessing a patient. Which assessment would cue the nurse to the potential of acute respiratory distress syndrome (ARDS)?

Increased peak inspiratory pressure on the ventilator

Which of the following are physiological effects of positive end-expiratory pressure (PEEP) used in the treatment of ARDS? (Select all that apply.)

Increases functional residual capacity Prevents collapse of unstable alveoli Improves arterial oxygenation Opens collapsed alveoli

Which of the following are components of the Institute for Healthcare Improvement's (IHI's) ventilator bundle? (Select all that apply.)

Interrupt sedation each day to assess readiness to extubate. Maintain head of bed at least 30 degrees of elevation. Provide deep vein thrombosis prophylaxis. Provide prophylaxis for peptic ulcer disease.

The nurse is caring for a patient who is being turned prone as part of treatment for acute respiratory distress syndrome. The nurse understands that the priority nursing concern for this patient is which of the following?

Management and protection of the airway

The nurse is concerned that a patient is at increased risk of developing a pulmonary embolus and develops a plan of care for prevention to include which of the following?

Mobility

A patient presents to the emergency department in acute respiratory failure secondary to community-acquired pneumonia. The patient has a history of chronic obstructive pulmonary disease. The nurse anticipates which treatment to facilitate ventilation?

Noninvasive positive-pressure ventilation (NPPV)

The nurse is assessing a patient with acute respiratory distress syndrome. An expected assessment is

PAOP of 10 mm Hg and PaO2 of 55.

Which of the following treatments may be used to dissolve a thrombus that is lodged in the pulmonary artery?

Thrombolytics

The etiology of noncardiogenic pulmonary edema in acute respiratory distress syndrome (ARDS) is related to damage to the

alveolar-capillary membrane.

During rounds, the provider alerts the team that proning is being considered for a patient with acute respiratory distress syndrome. The nurse understands that proning is

an optional treatment to improve ventilation.

A patient at high risk for pulmonary embolism is receiving enoxaparin. The nurse explains to the patient:

b. "This injection is being given to prevent blood clots from forming."

11. An acute exacerbation of asthma is treated with which of the following?

b. Inhaled bronchodilators and intravenous corticosteroids

4. Intrapulmonary shunting refers to

blood that is shunted from the right side of the heart to the left without oxygenation

Which of the following acid-base disturbances commonly occurs with the hyperventilation and impaired gas exchange seen in severe exacerbation of asthma?

c. Respiratory acidosis

19. A definitive diagnosis of pulmonary embolism can be made by

c. pulmonary angiogram.

7. The basic underlying pathophysiology of acute respiratory distress syndrome results in

damage to the type II pneumocytes, which produce surfactant.

The nurse is caring for a patient with a diagnosis of pulmonary embolism. The nurse understands that the most common cause of a pulmonary embolus is

deep vein thrombosis from lower extremities.

5. When fluid is present in the alveoli,

diffusion of oxygen and carbon dioxide is impaired.

The nurse is caring for a patient with acute respiratory distress syndrome who is hypoxemic despite mechanical ventilation. The provider prescribes a nontraditional ventilator mode as part of treatment. Despite sedation and analgesia, the patient remains restless and appears to be in discomfort. The nurse informs the provider of this assessment and anticipates an order for

neuromuscular blockade.

The nurse is caring for a patient with acute respiratory failure and identifies "Risk for Ineffective Airway Clearance" as a nursing diagnosis. A nursing intervention relevant to this diagnosis is to

reposition the patient every 2 hours.

6. In assessing a patient, the nurse understands that an early sign of hypoxemia is

restlessness

The nurse is discharging a patient with asthma. As part of the discharge instruction, the nurse instructs the patient to prevent exacerbation by:

taking all asthma medications as prescribed.