Ch. 67 Acute Respiratory Failure and ARDS

The nurse is caring for a 27-yr-old man with multiple fractured ribs from a motor vehicle crash. Which clinical manifestation, if experienced by the patient, is an early indication that the patient is developing respiratory failure? A Tachycardia and pursed lip breathing B Kussmaul respirations and hypotension C Frequent position changes and agitation D Cyanosis and increased capillary refill time

C Frequent position changes and agitation (A change in mental status is an early indication of respiratory failure. The brain is sensitive to variations in oxygenation, arterial carbon dioxide levels, and acid-base balance. Restlessness, confusion, agitation, and combative behavior suggest inadequate oxygen delivery to the brain.)

A patient is in acute respiratory distress syndrome (ARDS) as a result of sepsis. Which measure would be implemented to maintain cardiac output? A Administer crystalloid fluids. 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.

A Administer crystalloid fluids. (Low cardiac output may necessitate crystalloid fluids 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.)

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

a. Refractory hypoxemia (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.)

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

a. Restlessness (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)

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

a. Treatment of the underlying condition (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.)

The most common early clinical manifestations of ARDS that the nurse may observe are a. dyspnea and tachypnea. b. cyanosis and apprehension. c. hypotension and tachycardia. d. respiratory distress and frothy sputum.

a. dyspnea and tachypnea. (The initial presentation of acute respiratory distress syndrome (ARDS) is often subtle. At the time of the initial injury and for several hours up to 2 days afterward, the patient may not experience respiratory symptoms, or the patient may exhibit only dyspnea, tachypnea, cough, and restlessness.)

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

a. sepsis. (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 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)

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

A Diffusion limitation (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., acute respiratory distress syndrome, pneumonia). Alveolar hypoventilation occurs when there is a generalized decrease in ventilation (e.g., restrictive lung disease, central nervous system 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).)

The nurse in the cardiac care unit is caring for a patient who has developed acute respiratory failure. Which medication is used to decrease patient pulmonary congestion and agitation? A Morphine B Albuterol C Azithromycin D Methylprednisolone

A Morphine (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.)

When caring for older adult patients with respiratory failure, the nurse will add which intervention to individualize care? A Position the patient in the supine position primarily. B Assess frequently for signs and symptoms of delirium. C Provide early endotracheal intubation to reduce complications. D Delay activity and ambulation to provide additional healing time.

B Assess frequently for signs and symptoms of delirium. (Older adult patients are more predisposed to factors such as delirium, health care associated infections, and polypharmacy. Individualizing the older patient's care plan to address these factors will improve care. Older adult patients are not required to remain in a supine position only and should increase activity as soon as stability is determined. Endotracheal intubation is not provided early, and noninvasive positive pressure ventilation may be considered as an alternative. The nurse should consider that the aging process leads to decreased lung elastic recoil, weakened lung muscles and reduced gas exchange, which may make the patient difficult to wean from the ventilator.)

When caring for a patient with acute respiratory distress syndrome (ARDS), which finding indicates therapy is appropriate? 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

B PaO2 is greater than or equal to 60 mm Hg. (The overall goal in caring for the patient with ARDS is for the PaO2 to be greater than or equal to 60 mm 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 admitting a 45-yr-old 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 suggest to the nurse? A Spontaneous resolution of the acute asthma attack B An acute development of bilateral pleural effusions C Airway constriction requiring immediate interventions D Overworked intercostal muscles resulting in poor air exchange

C Airway constriction requiring immediate interventions (When a 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 airway patency. 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.)

The nurse is caring for a 37-yr-old female patient with multiple musculoskeletal injuries who has developed acute respiratory distress syndrome (ARDS). Which intervention should the nurse initiate to prevent stress ulcers? A Observe stools for frank bleeding and occult blood. B Maintain head of the bed elevation at 30 to 45 degrees. C Begin enteral feedings as soon as bowel sounds are present. D Administer prescribed lorazepam (Ativan) to reduce anxiety.

C Begin enteral feedings as soon as bowel sounds are present. (Stress ulcers prevention includes early initiation of enteral nutrition to protect the gastrointestinal (GI) tract from mucosal damage. Antiulcer agents such as histamine (H2)-receptor antagonists, proton pump inhibitors, and mucosal protecting agents are also indicated to prevent stress ulcers. Monitoring for GI bleeding does not prevent stress ulcers. Ventilator-associated pneumonia related to aspiration is prevented by elevation of the head of bed to 30 to 45 degrees Stress ulcers are not caused by anxiety. Stress ulcers are related to GI ischemia from hypotension, shock, and acidosis.)

The nurse is caring for a patient who is admitted with a barbiturate overdose. The patient is comatose with a blood pressure of 90/60 mm Hg, apical pulse of 110 beats/min, and respiratory rate of 8 breaths/min. Based on 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

C Hypercapnic respiratory failure related to alveolar hypoventilation (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 due to an obtunded airway causing decreased respiratory rate and thus decreased CO2 elimination. Barbiturate overdose does not lead to shunting of blood, diffusion limitations, or increased airway resistance.)

Arterial blood gas results are reported to the nurse for a 68-yr-old patient admitted with pneumonia: pH 7.31, PaCO2 49 mm Hg, HCO3 26 mEq/L, and PaO2 52 mm Hg. What order should the nurse complete first? A Administer albuterol inhaler prn. B Increase fluid intake to 2500 mL per 24 hours. C Initiate oxygen at 2 liters/minute by nasal cannula. D Perform chest physical therapy four times per day.

C Initiate oxygen at 2 liters/minute by nasal cannula. (The arterial blood gas results indicate the patient is in uncompensated respiratory acidosis with moderate hypoxemia. Oxygen therapy is indicated to correct hypoxemia secondary to V/Q mismatch. Supplemental oxygen should be initiated at 1 to 3 L/min by nasal cannula, or 24% to 32% by simple face mask or Venturi mask to improve the PaO2. Albuterol would be administered next if needed for bronchodilation. Hydration is indicated for thick secretions, and chest physical therapy is indicated for patients with 30 mL or more of sputum production per day.)

Which patient would most benefit from noninvasive positive pressure ventilation (NIPPV) 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

D A patient who is experiencing respiratory failure as a result of the progression of myasthenia gravis (NIPPV such as continuous positive airway pressure (CPAP) 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.)

A 56-yr-old man with acute respiratory distress syndrome (ARDS) is on positive pressure ventilation (PPV). The patient's cardiac index is 1.4 L/min and pulmonary artery wedge pressure is 8 mm Hg. What order by the physician is important for the nurse to question? A Initiate a dobutamine infusion at 3 mcg/kg/min. B Administer 1 unit of packed red blood cells over the next 2 hours. C Change the maintenance intravenous (IV) rate from 75 to 125 mL/hr. D Increase positive end-expiratory pressure (PEEP) from 10 to 15 cm H2O.

D Increase positive end-expiratory pressure (PEEP) from 10 to 15 cm H2O. (Patients on PPV and PEEP frequently experience decreased cardiac output (CO) and cardiac index (CI). High levels of PEEP increase intrathoracic pressure and cause decreased venous return which results in decreased CO. Interventions to improve CO include lowering the PEEP, administering crystalloid fluids or colloid solutions, and use of inotropic drugs (e.g., dobutamine, dopamine). Packed red blood cells may also be administered to improve CO and oxygenation if the hemoglobin is less than 9 or 10 mg/dL.)

A 72-yr-old woman with aspiration pneumonia develops severe respiratory distress. Her PaO2 is 42 mmHg and FIO2 is 80%. Which intervention should the nurse complete first? A Stat portable chest radiography B Administer lorazepam (Ativan) 1 mg IV push C Place the patient in a prone position on a rotational bed D Position the patient with arms supported away from the chest

D Position the patient with arms supported away from the chest (The nurse will first position the patient to facilitate ventilation. Additional oxygen support may be necessary. Refractory hypoxemia indicates the patient is not demonstrating acute lung injury but has now developed acute respiratory distress syndrome (ARDS). If the PaO2 is 42 mm Hg on 80% FIO2 (fraction of inspired oxygen; room air is 21% FIO2), then the PaO2/FIO2 ratio is 52.5, indicating ARDS (PaO2/FIO2 ratio < 200). Stat portable chest radiography may show worsening infiltrates or "white lung." A rotational bed placing the patient in prone position would be a strategy to use for select patients with ARDS. This patient's age, diagnosis, and comorbidities may indicate appropriateness for this treatment. Administration of lorazepam (Ativan) 1 mg may be harmful to this patient's oxygenation status. Further assessment would be needed to determine safety.)

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

a, b, d (Clinical manifestations that occur with hypoxemic respiratory failure include cyanosis, tachypnea, and paradoxic chest or abdominal wall movement with the respiratory cycle. Clinical manifestations of hypercapnic respiratory failure include morning headache, pursed-lip breathing, and decreased or increased respiratory rate with shallow breathing.)

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

a, c, d (Morphine and nitroglycerin 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.)

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

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

Which changes of aging contribute to the increased risk for respiratory failure in older adults (select all that apply)? a. Alveolar dilation b. Increased delirium muscle strength c. Changes in vital signs d. Increased infection risk e. Decreased respiratory 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 & receiving propofol(Diprivan) for sedation & fentanyl (Sublimaze) to decrease anxiety, agitation, & pain in order to decrease his work of breathing, O2 consumption, CO2 production & risk of injury. What intervention is recommended in caring for this patient? a. A sedation holiday b. Monitoring for hypermetabolism c. Keeping his legs still to avoid dislodging the airway d. Repositioning him every 4 hours to decrease agitation

a. A sedation holiday (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)

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

a. On the left side (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.)

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. Positive pressure ventilation (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. Prevent alveolar collapse and open up collapsed alveoli (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.)

Which descriptions are characteristic of hypoxemic respiratory failure (SATA)? 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 & 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 & ventilatory demand & the body is unable to compensate for the acidemia of increased PaCO2)

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

b. Decreasing blood pressure (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.)

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

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

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

b. Performing augmented coughing (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 & works well for patients with COPD to clear central airways. Slow pursed lip breathing allows more time for expiration and prevents small bronchioles from collapsing.)

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

b. Quality, quantity, and consistency of sputum (Ventilator-associated pneumonia (VAP) is one of the most common complications of ARDS. Early detection requires frequent monitoring of sputum smears & cultures & assessment of the quality, quantity, & 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 & impaired host defenses but are not common.)

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. Slow, shallow respirations as a result of sedative overdose (Hypercapnic respiratory failure is associated with alveolar hypoventilation with increases in alveolar and arterial carbon dioxide (CO2) & 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 & result in a V/Q mismatch or shunt typical of hypoxemic respiratory failure.

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

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

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. Continued hypoxemia because of diffusion limitation (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.)

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

c. Exhibits dyspnea and restlessness (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.)

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. Inadequate gas exchange to meet the metabolic needs of the body (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)

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

c. Provide O2 by aerosol mask (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.)

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

c. Pulmonary embolus (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.)

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. This occurs when blood flows through the capillaries in the lungs without participating in gas exchange. (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).)

Which intervention is most likely to prevent or limit barotrauma in the patient with ARDS who is mechanically ventilated? a. Decreasing PEEP b. Increasing the tidal volume c. Use of permissive hypercapnia d. Use of positive pressure ventilation

c. Use of permissive hypercapnia (To avoid barotrauma and minimize risk associated with elevated plateau and peak inspiratory pressures, many patient with ARDS are ventilated with smaller tidal volumes and varying amounts of positive end-expiratory pressure (PEEP) to minimize O2 requirements and intrathoracic pressures. One result of this protocol is an elevation in partial pressure of CO2 in arterial blood (PaCO2), called permissive hypercapnia because the PaCO2 is allowed to rise above normal limits.)

Maintenance of fluid balance in the patient with ARDS involves a. hydration using colloids. b. administration of surfactant. c. fluid restriction and diuretics as necessary. d. keeping the hemoglobin at levels above 9 g/dL (90 g/L).

c. fluid restriction and diuretics as necessary. (In a patient with ARDS, management of fluid balance includes limiting pulmonary edema by monitoring stroke volume variation or maintaining the pulmonary artery wedge pressure as low as possible without impairing cardiac output. Patients are often placed on fluid restriction, and diuretics are used as necessary.)

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

d. Has a change in respiratory rate from rapid to slow (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.)

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. Is alert and cooperative but has increasing respiratory exhaustion (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.)

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 b. PaO2 46 mm Hg, PaCO2 52 mm Hg, pH 7.36 c. PaO2 48 mm Hg, PaCO2 54 mm Hg, pH 7.38 d. PaO2 50 mm Hg, PaCO2 54 mm Hg, pH 7.28

d. PaO2 50 mm Hg, PaCO2 54 mm Hg, pH 7.28 (In a patient with normal lung function, respiratory failure is commonly defined as a PaO2 ≤60 mm Hg or a PaCO2 >45 mm Hg or both. However, because the patient with chronic pulmonary disease normally maintains low PaO2 and high PaCO2 , acute respiratory failure in these patients can be defined as an acute decrease in PaO2 or an increase in PaCO2 from the patient's baseline parameters, accompanied by an acidic pH. The pH of 7.28 reflects an acidemia and a loss of compensation in the patient with chronic lung disease.)

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

d. To evaluate cardiac status and blood flow to tissues (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.)

The O2 delivery system chosen for the patient in acute respiratoryfailure should: a. always be a low-flow device, such as a nasal cannula or face mask. b. administer continuous positive airway pressure ventilation to prevent CO2 narcosis. c. correct the PaO2 to a normal level as quickly as possible using mechanical ventilation. d. maintain the PaO2 at greater than or equal to 60 mm Hg at the lowest O2 concentration possible.

d. maintain the PaO2 at greater than or equal to 60 mm Hg at the lowest O2 concentration possible. (The selected O2 delivery system must maintain partial pressure of O2 in arterial blood (PaO2) at 55 to 60 mm Hg or higher and arterial O2 saturation (SaO2) at 90% or higher at the lowest O2 concentration possible.)

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. promote perfusion of nonatelectatic alveoli in the anterior portion of the lung. (When a patient with ARDS is supine, alveoli in the posterior areas of the lung are dependent & 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.)