CH 32: Acute Respiratory Failure (ARF) Flashcards
A 68-year-old male with a history of COPD is admitted to the ICU with worsening dyspnea, confusion, and lethargy. His arterial blood gas (ABG) results are:
* pH: 7.28
* PaCO2: 58 mm Hg
* PaO2: 65 mm Hg
* HCO3-: 25 mEq/L
* SpO2: 86% on room air
Which of the following interventions should the nurse anticipate?
A. Administering a high-flow oxygen mask at 100% FiO2
B. Preparing the patient for noninvasive positive-pressure ventilation (NIPPV)
C. Encouraging the patient to perform incentive spirometry
D. Increasing intravenous fluid administration to improve oxygen delivery
B. Preparing the patient for noninvasive positive-pressure ventilation (NIPPV)
Rationale: This patient is experiencing hypercapnic respiratory failure due to CO2 retention, as indicated by the high PaCO2 and acidemia (pH < 7.35). NIPPV, such as bilevel positive airway pressure (BiPAP), helps improve ventilation and CO2 removal without intubation.
A nurse is reviewing the pathophysiology of acute respiratory failure (ARF). Which statement best differentiates hypoxemic respiratory failure from hypercapnic respiratory failure?
A. Hypoxemic respiratory failure is caused by increased CO2 production, while hypercapnic respiratory failure results from inadequate CO2 removal.
B. Hypoxemic respiratory failure is characterized by a PaO2 < 60 mm Hg, while hypercapnic respiratory failure is characterized by a PaCO2 > 50 mm Hg.
C. Hypoxemic respiratory failure occurs primarily in COPD patients, while hypercapnic respiratory failure is seen in conditions like pulmonary embolism.
D. Hypoxemic respiratory failure primarily affects ventilation, whereas hypercapnic respiratory failure is a perfusion problem.
B. Hypoxemic respiratory failure is characterized by a PaO2 < 60 mm Hg, while hypercapnic respiratory failure is characterized by a PaCO2 > 50 mm Hg.
Rationale: Hypoxemic failure is primarily an oxygenation problem, while hypercapnic failure is a ventilatory issue leading to CO2 retention.
Which condition is most likely to cause hypoxemic respiratory failure?
A. Myasthenia gravis
B. Guillain-Barré syndrome
C. Opioid overdose
D. Pulmonary embolism
D. Pulmonary embolism
Rationale: A pulmonary embolism blocks blood flow to the lungs, impairing oxygenation and leading to hypoxemic respiratory failure.
Which finding suggests impending respiratory arrest in a patient with acute respiratory failure?
A. Accessory muscle use and tachypnea
B. PaCO2 of 60 mm Hg with lethargy
C. SpO2 of 92% with increased agitation
D. Respiratory rate of 24 breaths/min
B. PaCO2 of 60 mm Hg with lethargy
Rationale: Rising PaCO2 with decreasing mental status suggests worsening hypercapnia and imminent respiratory failure, requiring immediate intervention.
Which patient is at highest risk for acute-on-chronic respiratory failure?
A. A 52-year-old with asthma
B. A 68-year-old with COPD and pneumonia
C. A 45-year-old with a pulmonary embolism
D. A 30-year-old post-op patient receiving opioids
B. A 68-year-old with COPD and pneumonia
Rationale: Patients with chronic respiratory failure (e.g., COPD) are at high risk for acute-on-chronic respiratory failure, especially with infections like pneumonia.
A patient with ARF is intubated and on mechanical ventilation. The nurse notes increasing agitation, decreased SpO2, and high-pressure alarms on the ventilator. What is the priority action?
A. Increase the FiO2 setting
B. Administer IV sedation
C. Obtain an arterial blood gas
D. Assess the patient for signs of tube displacement or obstruction
D. Assess the patient for signs of tube displacement or obstruction
Rationale: High-pressure alarms suggest a potential airway obstruction, mucus plug, or tube displacement, requiring immediate assessment.
Which intervention is most appropriate for a patient with severe hypercapnic respiratory failure?
A. High-flow nasal cannula
B. Chest physiotherapy
C. Noninvasive ventilation (BiPAP)
D. Incentive spirometry
C. Noninvasive ventilation (BiPAP)
Rationale: BiPAP assists ventilation, removing CO2 and improving gas exchange in hypercapnic failure.
Which clinical sign indicates the early stages of hypoxemic respiratory failure?
A. Cyanosis and bradycardia
B. Altered mental status and hypotension
C. Restlessness and tachycardia
D. Decreased respiratory rate and lethargy
C. Restlessness and tachycardia
Rationale: Early signs of hypoxemia include restlessness, anxiety, and tachycardia due to increased sympathetic nervous system stimulation in response to low oxygen levels.
A 56-year-old patient with sepsis develops acute respiratory failure. The ABG results are:
- pH: 7.28
- PaCO2: 52 mm Hg
- PaO2: 58 mm Hg
- HCO3-: 22 mEq/L
Which pathophysiologic process best explains these findings?
A. Inadequate alveolar ventilation leading to CO2 retention
B. Increased metabolic demand causing respiratory alkalosis
C. Increased diffusion of oxygen at the alveolar-capillary level
D. Increased bicarbonate production leading to metabolic alkalosis
A. Inadequate alveolar ventilation leading to CO2 retention
Rationale: The high PaCO2 and low pH indicate hypercapnic respiratory failure due to inadequate ventilation, which is common in sepsis-related respiratory dysfunction.
A nurse is caring for a patient with ARF who is receiving BiPAP. Which finding requires immediate intervention?
A. Respiratory rate of 22 breaths/min
B. SpO2 of 94%
C. Patient is unable to remove secretions effectively
D. Mild agitation after mask placement
C. Patient is unable to remove secretions effectively
Rationale: BiPAP requires intact airway clearance. If the patient cannot clear secretions, intubation may be necessary to prevent mucus plugging and worsening respiratory failure.
Which oxygen delivery method is most appropriate for a patient with acute hypoxemic respiratory failure?
A. Nasal cannula at 2 L/min
B. Venturi mask at 50% FiO2
C. Simple face mask at 5 L/min
D. Non-rebreather mask at 100% FiO2
D. Non-rebreather mask at 100% FiO2
Rationale: A non-rebreather mask provides the highest FiO2 and is the best option for rapidly correcting severe hypoxemia before considering intubation.
Which ventilator setting improves oxygenation in a patient with hypoxemic respiratory failure?
A. Increasing FiO2
B. Increasing tidal volume
C. Decreasing respiratory rate
D. Lowering positive end-expiratory pressure (PEEP)
A. Increasing FiO2
Rationale: In hypoxemic respiratory failure, increasing FiO2 enhances arterial oxygenation by improving oxygen delivery to the alveoli.
A patient with acute respiratory failure has a PaO2 of 48 mm Hg despite receiving FiO2 of 100% via a non-rebreather mask. What is the next priority intervention?
A. Increase the FiO2 to 120%
B. Start BiPAP
C. Prepare for endotracheal intubation and mechanical ventilation
D. Obtain a repeat arterial blood gas in 30 minutes
C. Prepare for endotracheal intubation and mechanical ventilation
Rationale: A PaO2 < 50 mm Hg despite high FiO2 indicates refractory hypoxemia, which requires mechanical ventilation to ensure adequate oxygenation.
Which patient is at highest risk for developing hypercapnic respiratory failure?
A. A 62-year-old with myasthenia gravis experiencing muscle weakness
B. A 45-year-old with severe pneumonia and PaO2 of 50 mm Hg
C. A 30-year-old with an acute asthma attack
D. A 50-year-old with a pulmonary embolism
A. A 62-year-old with myasthenia gravis experiencing muscle weakness
Rationale: Neuromuscular disorders (e.g., myasthenia gravis) can cause respiratory muscle weakness, leading to CO2 retention and hypercapnic respiratory failure.
A patient is intubated for acute respiratory failure. Which ventilator alarm requires immediate assessment?
A. Low tidal volume alarm
B. High respiratory rate alarm
C. Low PEEP alarm
D. High FiO2 alarm
A. Low tidal volume alarm
Rationale: A low tidal volume alarm may indicate tube dislodgement, circuit disconnection, or inadequate ventilation, requiring immediate intervention.
Which assessment finding indicates worsening acute respiratory failure?
A. SpO2 of 94% on 2 L nasal cannula
B. Patient is drowsy and difficult to arouse
C. Respiratory rate of 18 breaths/min
D. ABG results showing PaCO2 of 45 mm Hg and pH of 7.40
B. Patient is drowsy and difficult to arouse
Rationale: Decreased level of consciousness suggests worsening hypercapnia and respiratory failure, requiring urgent intervention.
A patient with hypoxemic respiratory failure is found to have a ventilation-perfusion (V/Q) mismatch. Which condition is the most likely cause of this imbalance?
A. Pulmonary embolism
B. Guillain-Barré syndrome
C. Myasthenia gravis
D. Opioid overdose
A. Pulmonary embolism
Rationale: Pulmonary embolism disrupts perfusion (Q) without affecting ventilation (V), leading to a V/Q mismatch, a primary cause of hypoxemic respiratory failure.
A patient with pneumonia has worsening hypoxemia despite receiving 100% FiO2 via a non-rebreather mask. The provider suspects a shunt as the cause of the patient’s respiratory failure. Which best explains why the patient’s oxygenation is not improving?
A. Increased perfusion to well-ventilated alveoli
B. Increased CO2 retention
C. Increased ventilation-perfusion mismatch
D. Blood bypassing oxygenated alveoli
D. Blood bypassing oxygenated alveoli
Rationale: A shunt occurs when blood bypasses oxygenated alveoli due to collapsed or fluid-filled alveoli (as in pneumonia), leading to severe refractory hypoxemia that does not improve with supplemental oxygen.
A patient with interstitial lung disease develops diffusion limitation, leading to hypoxemic respiratory failure. Which pathophysiologic process is responsible for this?
A. Decreased alveolar capillary membrane surface area
B. Decreased CO2 retention due to increased ventilation
C. Shunting of blood away from affected lung regions
D. Increased pulmonary artery pressure causing V/Q mismatch
A. Decreased alveolar capillary membrane surface area
Rationale: In diffusion limitation, conditions like interstitial lung disease cause fibrosis and thickening of the alveolar-capillary membrane, impairing oxygen diffusion and leading to hypoxemia.
Which primary mechanism is involved in alveolar hypoventilation leading to hypoxemic respiratory failure?
A. Increased airway resistance and lung hyperinflation
B. Impaired oxygen diffusion across the alveolar membrane
C. Intrapulmonary shunting of deoxygenated blood
D. Decreased respiratory drive or muscle weakness
D. Decreased respiratory drive or muscle weakness
Rationale: Alveolar hypoventilation occurs when there is insufficient ventilation, often due to decreased respiratory drive (e.g., CNS depression) or neuromuscular weakness, leading to hypoxemia and hypercapnia.
A patient with ARDS (acute respiratory distress syndrome) is intubated and mechanically ventilated. The nurse notes persistently low PaO2 levels despite FiO2 of 100%. The provider diagnoses refractory hypoxemia due to a pulmonary shunt. Which intervention is the most appropriate to improve oxygenation?
A. Increase FiO2 to 120%
B. Increase the respiratory rate to 35 breaths/min
C. Administer a high-dose opioid for sedation
D. Implement prone positioning
D. Implement prone positioning
Rationale: Prone positioning improves ventilation-perfusion matching, reduces shunting, and enhances alveolar recruitment, making it the most effective intervention for refractory hypoxemia in ARDS.
A patient with COPD is experiencing hypoxemia due to a V/Q mismatch. Which physiologic mechanism is responsible for this imbalance?
A. Increased airway secretions blocking alveolar ventilation
B. Decreased pulmonary blood flow due to vascular occlusion
C. Reduced metabolic demand leading to oxygen conservation
D. Overactive central chemoreceptors decreasing respiratory rate
A. Increased airway secretions blocking alveolar ventilation
Rationale: In COPD, excessive airway secretions impair alveolar ventilation, leading to poor oxygenation while blood flow remains intact, causing a V/Q mismatch.
A post-operative patient is reporting severe abdominal pain and is reluctant to take deep breaths. The nurse notes decreasing SpO2 levels and shallow respirations. What is the most likely cause of this patient’s V/Q mismatch?
A. Pulmonary embolism
B. Hyperventilation
C. Atelectasis
D. Excessive perfusion
C. Atelectasis
Rationale: Pain-related splinting leads to shallow breathing, promoting alveolar collapse (atelectasis), reducing ventilation and causing a V/Q mismatch.
A patient with asthma experiences bronchospasms leading to hypoxemia. Which factor contributes most to this patient’s V/Q mismatch?
A. Decreased ventilation with normal perfusion
B. Decreased perfusion with normal ventilation
C. Increased ventilation and perfusion
D. Increased diffusion capacity of alveoli
A. Decreased ventilation with normal perfusion
Rationale: Bronchospasms reduce ventilation, while blood flow (perfusion) remains normal, causing a V/Q mismatch with inadequate oxygenation.
A patient with pneumonia has V/Q mismatch due to alveolar secretions. What is the best initial intervention?
A. Heparin infusion
B. Diuretic administration
C. Chest physiotherapy
D. Oxygen therapy
D. Oxygen therapy
Rationale: Oxygen therapy is the first-line intervention for hypoxemia due to V/Q mismatch, though the underlying cause (e.g., secretions) must also be treated.
A patient with a massive pulmonary embolism (PE) has hypoxemia and hypotension. What is the primary mechanism causing this patient’s V/Q mismatch?
A. Increased metabolic demand increasing CO2 production
B. Overproduction of surfactant reducing alveolar expansion
C. Hyperventilation causing respiratory alkalosis
D. Impaired perfusion distal to the embolism
D. Impaired perfusion distal to the embolism
Rationale: A pulmonary embolism blocks blood flow to lung tissue, decreasing perfusion, while ventilation remains normal, resulting in a V/Q mismatch.
Which clinical sign would the nurse expect in a patient with a significant V/Q mismatch?
A. Bradycardia and hypotension
B. Restlessness and confusion
C. Decreased respiratory rate
D. Increased urine output
B. Restlessness and confusion
Rationale: Hypoxemia from V/Q mismatch first manifests as restlessness, agitation, and confusion due to cerebral hypoxia.
A nurse is caring for a patient with pulmonary embolism (PE). Which intervention would most effectively address hypoxemia from a V/Q mismatch?
A. High-dose corticosteroids
B. Fluid restriction
C. Increased dietary protein
D. Immediate administration of thrombolytics
D. Immediate administration of thrombolytics
Rationale: Thrombolytics dissolve the clot, restoring pulmonary blood flow, thereby correcting the V/Q mismatch caused by decreased perfusion.
A patient with severe pneumonia is placed on 100% FiO2 but remains hypoxemic. What is the most likely reason for persistent V/Q mismatch despite oxygen therapy?
A. Reduced hemoglobin affinity for oxygen
B. O2 cannot reach alveoli due to secretions
C. Increased respiratory drive improving ventilation
D. Compensatory decrease in metabolic demand
B. O2 cannot reach alveoli due to secretions
Rationale: In pneumonia, secretions block alveolar ventilation, preventing oxygen from reaching perfused areas, leading to persistent hypoxemia despite O2 therapy.
What is the primary goal of oxygen therapy in patients with V/Q mismatch?
A. Increase PaO2 to improve tissue oxygenation
B. Decrease alveolar ventilation to retain CO2
C. Reduce pulmonary blood flow to decrease demand
D. Lower hemoglobin levels to prevent oxygen toxicity
A. Increase PaO2 to improve tissue oxygenation
Rationale: The goal of oxygen therapy in V/Q mismatch is to increase PaO2, improving oxygen delivery to tissues.
A V/Q mismatch occurs when:
A. Ventilation and perfusion are not equal
B. Blood bypasses oxygenated alveoli
C. Oxygen cannot diffuse across a thickened alveolar membrane
D. Ventilation is entirely absent
A. Ventilation and perfusion are not equal
Rationale: A V/Q mismatch occurs when ventilation and perfusion are imbalanced, leading to hypoxemia.
A post-operative patient has shallow breathing due to pain. What action should the nurse take to prevent atelectasis-related V/Q mismatch?
A. Administer diuretics
B. Limit deep breathing to prevent pain
C. Encourage incentive spirometry
D. Position the patient supine
C. Encourage incentive spirometry
Rationale: Incentive spirometry promotes deep breathing and lung expansion, reducing atelectasis, a key contributor to V/Q mismatch.
A patient with V/Q mismatch due to asthma is receiving oxygen therapy. The nurse should monitor for:
A. Decreased PaCO2 levels
B. Increased urine output
C. Metabolic alkalosis
D. Hyperkalemia
A. Decreased PaCO2 levels
Rationale: Oxygen therapy may improve ventilation and lower PaCO2, especially if hyperventilation occurs.
A patient with a V/Q mismatch due to atelectasis has a SpO2 of 86%. Which intervention is the most appropriate?
A. Increase IV fluid administration
B. Restrict oxygen therapy
C. Administer high-dose sedatives
D. Initiate positive-pressure ventilation
D. Initiate positive-pressure ventilation
Rationale: Positive-pressure ventilation helps reopen collapsed alveoli, improving oxygenation in atelectasis-related V/Q mismatch.
Which condition most commonly causes V/Q mismatch in post-operative patients?
A. Atelectasis
B. Pulmonary hypertension
C. Metabolic acidosis
D. Anemia
A. Atelectasis
Rationale: Atelectasis due to shallow breathing is a common cause of V/Q mismatch in post-operative patients.
A patient with severe pneumonia is experiencing hypoxemia that does not improve with supplemental oxygen. The nurse suspects a shunt as the cause of this hypoxemia. What is the underlying mechanism?
A. Alveolar ventilation is mismatched with pulmonary perfusion
B. Blood bypasses ventilated alveoli without participating in gas exchange
C. Oxygen is unable to diffuse across a thickened alveolar membrane
D. Excessive carbon dioxide is retained due to alveolar hypoventilation
B. Blood bypasses ventilated alveoli without participating in gas exchange
Rationale: A pulmonary capillary shunt occurs when blood passes through pulmonary capillaries without participating in gas exchange due to alveolar filling (e.g., pneumonia, pulmonary edema). Unlike V/Q mismatch, which responds to oxygen therapy, a shunt does not because alveoli are completely filled with fluid, preventing oxygen diffusion into the bloodstream.
A postoperative cardiac surgery patient develops profound hypoxemia despite receiving 100% oxygen via a non-rebreather mask. The nurse suspects an anatomic shunt. Which condition is most likely responsible for this?
A. Acute pulmonary embolism
B. Ventricular septal defect
C. Bronchospasm from anesthesia
D. Acute respiratory alkalosis
B. Ventricular septal defect
Rationale: An anatomic shunt occurs when blood bypasses the lungs completely, such as in congenital heart defects like a VSD, where deoxygenated blood is shunted from the right to left heart without undergoing pulmonary gas exchange. This type of hypoxemia does not improve with oxygen therapy because the affected blood never reaches the alveoli. Unlike V/Q mismatch, which responds to oxygen therapy, an anatomic shunt requires surgical intervention.
A patient with ARDS (acute respiratory distress syndrome) has bilateral pulmonary infiltrates and severe refractory hypoxemia despite receiving high-flow oxygen therapy. The provider orders mechanical ventilation with high FiO₂ and PEEP. What is the primary reason for using PEEP in this patient?
A. To remove fluid from the alveoli and increase blood perfusion
B. To reduce pulmonary capillary blood flow and prevent shunting
C. To reopen collapsed alveoli and improve gas exchange
D. To increase carbon dioxide elimination and decrease respiratory acidosis
C. To reopen collapsed alveoli and improve gas exchange
Rationale: ARDS leads to a capillary shunt because fluid-filled alveoli prevent oxygenation. Positive end-expiratory pressure (PEEP) helps to keep alveoli open, recruit collapsed alveoli, and improve oxygen diffusion. Without PEEP, blood continues passing through non-ventilated alveoli, worsening shunting and leading to refractory hypoxemia. Oxygen therapy alone is ineffective in shunt-related hypoxemia, making PEEP essential.
Which patient is at the highest risk for developing a pulmonary capillary shunt?
A. A patient with asthma experiencing a mild bronchospasm
B. A patient with chronic obstructive pulmonary disease (COPD) receiving low-flow oxygen
C. A patient with lobar pneumonia and diffuse alveolar consolidation
D. A patient with a pulmonary embolism affecting a segmental artery
C. A patient with lobar pneumonia and diffuse alveolar consolidation
Rationale: A capillary shunt occurs when alveoli are completely filled with fluid, preventing gas exchange. Lobar pneumonia leads to extensive alveolar consolidation, meaning oxygen cannot diffuse across the alveolar-capillary membrane, resulting in refractory hypoxemia. This differs from V/Q mismatch, where ventilation is only partially impaired and responds to oxygen therapy.
A patient with ARDS remains hypoxemic despite 100% FiO₂. The mechanical ventilator settings are adjusted to include high PEEP. Which physiological change is expected with this intervention?
A. Decreased pulmonary blood flow and increased shunting
B. Increased respiratory acidosis due to CO₂ retention
C. Reduced oxygen diffusion due to capillary thickening
D. Increased alveolar recruitment and improved oxygenation
D. Increased alveolar recruitment and improved oxygenation
Rationale: High PEEP is crucial in treating shunt-related hypoxemia because it helps reopen collapsed alveoli, improving oxygenation in ARDS. Unlike V/Q mismatch, shunt-related hypoxemia does not respond to supplemental oxygen alone. Without PEEP, blood continues to bypass ventilated alveoli, worsening hypoxemia.
The nurse is caring for a patient with pneumonia and severe hypoxemia that does not respond to oxygen therapy. Which diagnostic test would best confirm the presence of a capillary shunt?
A. Arterial blood gas (ABG) with increased PaCO₂
B. Pulmonary function test showing obstructive disease
C. Echocardiogram with bubble study
D. Chest x-ray showing alveolar infiltrates
D. Chest x-ray showing alveolar infiltrates
Rationale: A capillary shunt in pneumonia occurs because fluid-filled alveoli prevent oxygen diffusion, leading to refractory hypoxemia. A chest x-ray would show consolidation and infiltrates, confirming alveolar filling as the cause. Unlike V/Q mismatch, where oxygen therapy helps, a shunt requires mechanical ventilation to restore gas exchange.
A mechanically ventilated patient with ARDS has a PaO₂ of 50 mmHg despite receiving 100% FiO₂. What is the best next intervention?
A. Increase PEEP to improve alveolar recruitment
B. Administer bronchodilators to open the airways
C. Switch to a non-rebreather mask
D. Decrease FiO₂ to prevent oxygen toxicity
A. Increase PEEP to improve alveolar recruitment
Rationale: In ARDS, shunting occurs when alveoli collapse or fill with fluid, preventing oxygenation. Increasing PEEP keeps alveoli open, allowing oxygen diffusion to improve PaO₂ levels. Oxygen therapy alone does not correct hypoxemia caused by a shunt, making PEEP a necessary intervention.
A patient with a congenital heart defect has persistent hypoxemia despite high-flow oxygen therapy. The provider suspects an anatomic shunt. What is the best long-term treatment?
A. Surgical correction of the cardiac defect
B. Increasing FiO₂ to 100%
C. Diuretic therapy to reduce pulmonary edema
D. Prone positioning to improve oxygenation
A. Surgical correction of the cardiac defect
Rationale: An anatomic shunt occurs when blood bypasses the lungs entirely, such as in congenital heart defects (e.g., ventricular septal defect). Since the affected blood never reaches ventilated alveoli, oxygen therapy is ineffective. The only definitive treatment is surgical correction to restore normal circulation and oxygenation.
A patient with pulmonary fibrosis reports increased shortness of breath and worsening hypoxemia during physical activity. What is the most likely cause of this symptom?
A. Ventilation-perfusion (V/Q) mismatch due to airway obstruction
B. Decreased time for oxygen diffusion due to increased cardiac output
C. Hypoventilation leading to retention of carbon dioxide
D. Increased perfusion to diseased lung tissue, improving gas exchange
B. Decreased time for oxygen diffusion due to increased cardiac output
Rationale: Diffusion impairment worsens with exercise because increased cardiac output (CO) accelerates blood flow through the pulmonary capillaries, reducing the time available for oxygen diffusion. In pulmonary fibrosis, the thickened alveolar-capillary membrane already slows oxygen diffusion, and rapid blood flow exacerbates hypoxemia. Unlike V/Q mismatch, which responds to oxygen therapy, diffusion impairment requires interventions that improve oxygenation efficiency, such as pulmonary rehabilitation and supplemental oxygen.
A mechanically ventilated patient with ARDS develops persistent hypoxemia despite 100% FiO₂. The nurse notes bilateral pulmonary infiltrates and interstitial thickening on a chest x-ray. What is the most likely cause of this patient’s hypoxemia?
A. Reduced alveolar ventilation due to airway obstruction
B. Impaired gas exchange due to alveolar-capillary membrane thickening
C. Increased pulmonary perfusion, causing V/Q mismatch
D. Hypercapnia leading to respiratory alkalosis
B. Impaired gas exchange due to alveolar-capillary membrane thickening
Rationale: ARDS leads to diffuse alveolar damage, causing fibrosis and thickening of the alveolar-capillary membrane, which slows oxygen diffusion. Even with high FiO₂, oxygen transport remains impaired, resulting in persistent hypoxemia. Unlike V/Q mismatch, where ventilation and perfusion are imbalanced, diffusion impairment is due to structural changes in the alveolar membrane, making oxygen therapy alone ineffective.
A patient with interstitial lung disease (ILD) experiences progressive hypoxemia. Which diagnostic test would best confirm diffusion impairment as the cause?
A. Arterial blood gas (ABG) analysis with PaO₂ and PaCO₂ levels
B. High-resolution computed tomography (HRCT) scan
C. Pulmonary function test (PFT) with diffusion capacity of carbon monoxide (DLCO)
D. Chest x-ray showing lung opacities
C. Pulmonary function test (PFT) with diffusion capacity of carbon monoxide (DLCO)
Rationale: DLCO measures how well oxygen and carbon monoxide diffuse across the alveolar-capillary membrane. In diffusion impairment disorders (e.g., pulmonary fibrosis, ILD), DLCO is decreased due to thickened alveolar walls. Unlike ABGs, which assess current gas exchange, DLCO directly measures diffusion capacity, making it the most specific test for diagnosing diffusion impairment.
Which clinical finding is most characteristic of diffusion impairment?
A. Sudden onset of severe dyspnea with chest pain
B. Hypercapnia with metabolic acidosis
C. Increased oxygen saturation with deep breathing
D. Worsening hypoxemia with exercise but normal oxygenation at rest
D. Worsening hypoxemia with exercise but normal oxygenation at rest
Rationale: A hallmark of diffusion impairment is hypoxemia that worsens with exertion but remains stable at rest. During exercise, cardiac output increases, accelerating pulmonary blood flow and reducing the time available for oxygen diffusion across the thickened alveolar-capillary membrane. Unlike V/Q mismatch, which can occur at rest, diffusion impairment is most evident during increased circulatory demand.
Which patient is at the highest risk for developing diffusion impairment?
A. A patient with COPD and chronic bronchospasm
B. A patient with mild asthma with occasional wheezing
C. A patient with obstructive sleep apnea on CPAP therapy
D. A patient with pulmonary fibrosis and chronic hypoxemia
D. A patient with pulmonary fibrosis and chronic hypoxemia
Rationale: Pulmonary fibrosis leads to thickening and scarring of the alveolar-capillary membrane, which slows oxygen diffusion and causes progressive hypoxemia. This is the primary mechanism of diffusion impairment. Unlike COPD and asthma, which are primarily obstructive diseases affecting airway resistance, pulmonary fibrosis specifically disrupts the gas exchange surface, making it the most likely cause of diffusion impairment.
A patient with high-output heart failure reports severe dyspnea and worsening hypoxemia during activity. The provider explains that diffusion impairment is contributing to the patient’s hypoxemia. What is the best explanation for this process?
A. Rapid blood flow through the pulmonary capillaries reduces oxygen diffusion time
B. Fluid accumulation in the alveoli blocks oxygen diffusion
C. Hypercapnia due to hypoventilation increases respiratory acidosis
D. Bronchospasm causes airway narrowing, reducing oxygen delivery
A. Rapid blood flow through the pulmonary capillaries reduces oxygen diffusion time
Rationale: In high-output heart failure, cardiac output is excessively high, leading to rapid circulation through the lungs. This reduces the time for oxygen diffusion across the alveolar-capillary membrane, causing exercise-induced hypoxemia. Unlike pulmonary edema, which involves fluid accumulation, this form of diffusion impairment is related to circulation speed rather than alveolar obstruction.
A patient with pulmonary edema is experiencing severe hypoxemia. What is the primary cause of diffusion impairment in this condition?
A. Bronchospasm restricts airflow to alveoli, reducing ventilation
B. Fluid accumulation in the alveoli increases the diffusion distance for oxygen
C. Pulmonary embolism reduces blood flow, causing a V/Q mismatch
D. Hypoventilation leads to carbon dioxide retention and acidosis
B. Fluid accumulation in the alveoli increases the diffusion distance for oxygen
Rationale: Pulmonary edema results in fluid accumulation in the alveoli, which increases the distance oxygen must travel to reach the bloodstream, slowing diffusion and causing hypoxemia. Unlike V/Q mismatch, which affects ventilation-perfusion balance, diffusion impairment is due to a physical barrier (fluid, protein, or inflammatory cells) preventing normal oxygen exchange.
Which intervention is most effective in improving oxygenation in patients with diffusion impairment due to interstitial lung disease?
A. Non-invasive positive pressure ventilation (NIPPV)
B. Diuretic therapy
C. Supplemental oxygen therapy
D. Bronchodilator therapy
C. Supplemental oxygen therapy
Rationale: In diffusion impairment disorders, increasing FiO₂ improves the pressure gradient for oxygen diffusion, enhancing oxygenation despite the thickened alveolar-capillary membrane. While NIPPV may help in some cases, the primary intervention for diffusion impairment is supplemental oxygen.
Which exercise recommendation is most appropriate for a patient with diffusion impairment due to pulmonary fibrosis?
A. High-intensity interval training (HIIT) to build endurance
B. Extended aerobic workouts to improve oxygenation
C. Avoiding exercise to prevent exertional hypoxemia
D. Low-intensity exercise with oxygen supplementation
D. Low-intensity exercise with oxygen supplementation
Rationale: Exercise increases cardiac output, worsening diffusion impairment. However, low-intensity exercise with oxygen therapy can improve functional status while preventing severe desaturation. Avoiding exercise entirely leads to deconditioning, worsening respiratory function over time.
What is the best way to monitor disease progression in a patient with diffusion impairment from pulmonary fibrosis?
A. Daily peak expiratory flow (PEF) measurements
B. Routine chest x-rays
C. Blood glucose monitoring
D. Serial pulmonary function tests with DLCO measurements
D. Serial pulmonary function tests with DLCO measurements
Rationale: DLCO specifically measures diffusion capacity, making it the best indicator of disease progression in pulmonary fibrosis. Unlike peak flow, which assesses airway obstruction, DLCO directly evaluates alveolar-capillary membrane function.
A patient with restrictive lung disease is exhibiting signs of hypoventilation and increased PaCO₂. Which of the following is the most likely cause of this patient’s alveolar hypoventilation?
A. Decreased lung compliance, limiting effective ventilation
B. Increased airway resistance, reducing airflow
C. Pulmonary embolism, blocking blood flow to the lungs
D. Increased respiratory drive, causing rapid breathing
A. Decreased lung compliance, limiting effective ventilation
Rationale: Restrictive lung disease leads to decreased lung compliance, which limits the expansion of the lungs and reduces effective ventilation. As a result, alveolar hypoventilation occurs, causing increased PaCO₂. Unlike conditions causing increased airway resistance (e.g., asthma), restrictive lung disease primarily impairs the lung’s ability to expand, preventing adequate ventilation and contributing to hypercapnia.
A patient with acute asthma experiences worsening dyspnea and hypercapnia due to alveolar hypoventilation. Which of the following mechanisms is most likely responsible for this patient’s condition?
A. Airway obstruction causing reduced ventilation and air trapping
B. Pulmonary edema preventing adequate gas exchange
C. Thoracic cage rigidity limiting the ability to breathe deeply
D. Increased blood viscosity reducing oxygen transport
A. Airway obstruction causing reduced ventilation and air trapping
Rationale: In acute asthma, bronchoconstriction and airway inflammation cause airway obstruction, leading to reduced ventilation and air trapping. This results in hypoventilation and hypercapnia, as inadequate gas exchange occurs in the obstructed airways. Unlike restrictive lung diseases, asthma primarily causes airway obstruction rather than issues with lung compliance.
A patient with a central nervous system (CNS) disorder presents with slow, shallow respirations, increased PaCO₂, and hypoxemia. What is the most likely cause of this patient’s alveolar hypoventilation?
A. Increased lung compliance, reducing the ability to eliminate CO₂
B. Impaired respiratory drive due to CNS dysfunction
C. Pulmonary edema leading to ventilation-perfusion mismatch
D. Bronchospasm limiting airflow and ventilation
B. Impaired respiratory drive due to CNS dysfunction
Rationale: CNS disorders can impair the respiratory centers in the brain, resulting in hypoventilation and hypercapnia. This occurs because the brain fails to adequately stimulate the respiratory muscles, leading to decreased ventilation and increased PaCO₂. Unlike conditions affecting lung compliance or airway resistance, CNS dysfunction directly affects the neural control of respiration.
A patient with chest wall dysfunction develops hypoventilation and an elevated PaCO₂. Which of the following is the most likely contributing factor to this patient’s alveolar hypoventilation?
A. Pulmonary embolism, impairing blood flow through the lungs
B. Decreased airway resistance, leading to insufficient air entry
C. Reduced chest wall expansion, limiting ventilation volume
D. Excessive fluid accumulation in the lungs, impairing gas exchange
C. Reduced chest wall expansion, limiting ventilation volume
Rationale: Chest wall dysfunction (e.g., rib fractures or neuromuscular disease) impairs the mechanical ability to expand the chest during breathing. This limits ventilation volume, leading to alveolar hypoventilation and increased PaCO₂. Unlike conditions like pulmonary embolism or fluid accumulation, chest wall dysfunction directly restricts the ability to effectively move air into the lungs, contributing to hypercapnia.
A patient with pneumonia develops acute hypoxemic respiratory failure (ARF). Which of the following combinations of mechanisms is most likely contributing to this patient’s condition?
A. Shunt and alveolar hypoventilation
B. V/Q mismatch and diffusion impairment
C. Alveolar hypoventilation and pulmonary embolism
D. V/Q mismatch and shunt
D. V/Q mismatch and shunt
Rationale: In pneumonia, inflammation, edema, and exudate can cause V/Q mismatch and shunt. V/Q mismatch occurs when airways are obstructed by inflammation or exudate, preventing adequate ventilation in some areas of the lung. Simultaneously, shunt occurs when fluid-filled alveoli impair gas exchange, leading to unoxygenated blood returning to the left side of the heart. These mechanisms together contribute to acute hypoxemic respiratory failure.
A patient with acute respiratory failure due to pneumonia presents with increasing anxiety and unrelieved pain. How might these factors exacerbate the patient’s condition?
A. Increased O2 demand further exacerbates hypoxemia
B. Increased ventilation helps to improve gas exchange
C. Decreased blood flow reduces oxygen delivery to tissues
D. Increased airway resistance leads to further airway obstruction
A. Increased O2 demand further exacerbates hypoxemia
Rationale: Anxiety and unrelieved pain increase oxygen demand by elevating the metabolic rate and increasing sympathetic nervous system activity, which can lead to increased respiratory rate and heart rate. This further exacerbates hypoxemia by increasing the oxygen requirements without improving ventilation or perfusion. Unlike the other options, the body cannot meet this increased oxygen demand in the presence of ARF, leading to worsening respiratory failure.
A patient with acute hypoxemic respiratory failure due to a combination of V/Q mismatch and shunt from pneumonia shows poor response to oxygen therapy. Which of the following best explains why this patient may not improve with supplemental oxygen alone?
A. Shunt prevents oxygen from reaching the pulmonary capillaries for gas exchange
B. V/Q mismatch does not respond to supplemental oxygen therapy
C. Shunt is responsive to O2 therapy, but V/Q mismatch is not
D. Increased blood viscosity reduces oxygen delivery to tissues
A. Shunt prevents oxygen from reaching the pulmonary capillaries for gas exchange
Rationale: Shunt occurs when blood bypasses the lungs and does not participate in gas exchange. Oxygen therapy alone is ineffective in improving PaO₂ in patients with shunt because the unoxygenated blood cannot be oxygenated. V/Q mismatch, on the other hand, can often be improved with supplemental oxygen, but shunt leads to persistent hypoxemia despite increased oxygen levels in the air.
A patient with acute respiratory failure (ARF) from pneumonia presents with increased anxiety, tachypnea, and hypoxemia. Which of the following is the most likely reason why this patient’s anxiety worsens the condition?
A. Anxiety decreases ventilation and worsens gas exchange
B. Anxiety increases respiratory effort and leads to airway collapse
C. Anxiety increases metabolic demand, worsening oxygenation
D. Anxiety stimulates sympathetic response, improving circulation and oxygenation
C. Anxiety increases metabolic demand, worsening oxygenation
Rationale: Anxiety increases sympathetic nervous system activity, leading to higher metabolic demand for oxygen, which worsens the already compromised oxygenation in ARF. As the patient’s body tries to meet this increased oxygen demand, it cannot do so due to impaired gas exchange
A patient with hypoxemia is at risk for developing hypoxia. Which of the following would be the most concerning consequence if hypoxia is left untreated?
A. Increased aerobic metabolism and enhanced cellular energy production
B. Cellular shift from aerobic to anaerobic metabolism, leading to lactic acid production
C. Increased oxygen availability to tissues, leading to improved tissue function
D. Normalization of pH due to the buffering effect of CO2
B. Cellular shift from aerobic to anaerobic metabolism, leading to lactic acid production
Rationale: When hypoxia occurs, cells shift from aerobic to anaerobic metabolism to meet energy demands. Anaerobic metabolism produces lactic acid, which is less efficient and results in the accumulation of waste products. This accumulation of lactic acid is problematic because it leads to metabolic acidosis. Left untreated, the body’s ability to clear lactic acid diminishes, worsening tissue and cellular function.
A nurse is caring for a patient with severe hypoxemia. What is the primary consequence of continued hypoxia at the cellular level?
A. Increased production of ATP through aerobic metabolism
B. Reduction in oxygen supply to mitochondria, impairing cellular function
C. Enhanced removal of waste products, including lactic acid
D. Improved energy production through more efficient metabolic pathways
B. Reduction in oxygen supply to mitochondria, impairing cellular function
Rationale: In the presence of hypoxia, oxygen supply to mitochondria is reduced, impairing the normal cellular processes that depend on aerobic metabolism. This leads to a shift to anaerobic metabolism, which is less efficient and results in the production of lactic acid. This acid buildup causes metabolic acidosis and disrupts normal cellular function.
Which of the following is a direct result of anaerobic metabolism due to hypoxia?
A. Increased ATP production and enhanced cellular function
B. Increased clearance of waste products from cellular metabolism
C. Improved oxygenation of tissues due to increased cellular efficiency
D. Production of lactic acid, leading to metabolic acidosis
D. Production of lactic acid, leading to metabolic acidosis
Rationale: Anaerobic metabolism is less efficient than aerobic metabolism, and its byproduct is lactic acid. The accumulation of lactic acid in the body leads to metabolic acidosis, as the body struggles to buffer and remove the acid. This is a critical consequence of hypoxia that exacerbates cellular dysfunction.
A patient has hypoxemia that progresses to hypoxia. Which of the following will most likely occur as a result of metabolic acidosis due to lactic acid buildup?
A. Increased cellular energy production through more efficient metabolism
B. Altered enzyme function and cellular disruption
C. Increased oxygen supply to tissues, leading to improved organ function
D. Decreased production of lactic acid and improved cellular function
B. Altered enzyme function and cellular disruption
Rationale: Metabolic acidosis from lactic acid buildup can disrupt enzyme function and compromise cellular function. This is because acidotic conditions can alter the activity of enzymes, leading to a breakdown of normal cellular processes and tissue dysfunction. Without treatment, these changes can progress to cell death.
A patient with untreated hypoxia has elevated lactic acid levels. Which of the following findings would the nurse most likely observe in this patient?
A. Improved mental status and increased alertness
B. Increased heart rate and decreased blood pressure
C. Increased respiratory rate and shallow breathing
D. Decreased respiratory rate and cyanosis
C. Increased respiratory rate and shallow breathing
Rationale: In response to hypoxia and metabolic acidosis, the body tries to compensate by increasing the respiratory rate to remove CO2 and buffer lactic acid. However, the patient may also demonstrate shallow breathing due to decreased lung compliance and fatigue. This leads to inadequate oxygenation, worsening the condition.
Which of the following best describes the impact of lactic acid buildup on the body during hypoxia?
A. Lactic acid accumulation decreases the oxygen demand of tissues
B. Lactic acid improves cellular function by increasing energy availability
C. Lactic acid enhances the body’s ability to clear waste products from cells
D. Lactic acid must be buffered with sodium bicarbonate, which can lead to metabolic acidosis
D. Lactic acid must be buffered with sodium bicarbonate, which can lead to metabolic acidosis
Rationale: Lactic acid is a byproduct of anaerobic metabolism and must be buffered with sodium bicarbonate in the body. If there is insufficient sodium bicarbonate to neutralize the acid, metabolic acidosis occurs. This worsens the patient’s condition, leading to further cellular dysfunction and, if left untreated, cell death.
What is the most likely consequence of hypoxemia progressing to severe hypoxia without intervention?
A. Enhanced tissue repair and faster recovery
B. Tissue and cellular dysfunction progressing to cell death
C. Increased oxygen delivery to tissues to improve function
D. Decreased lactic acid buildup, improving pH balance
B. Tissue and cellular dysfunction progressing to cell death
Rationale: If hypoxemia progresses to severe hypoxia, cells begin to rely on anaerobic metabolism, leading to the accumulation of lactic acid and metabolic acidosis. This disrupts normal cellular processes, resulting in tissue and cellular dysfunction. Without correction, this process can ultimately lead to cell death, organ failure, and systemic collapse.
A patient is diagnosed with acute hypercapnic respiratory failure. Which of the following is the most likely cause of this condition?
A. Increased CO2 production or decreased alveolar ventilation
B. Increased oxygen supply and efficient gas exchange
C. Normal lung function with enhanced alveolar ventilation
D. Decreased CO2 production due to impaired metabolic activity
A. Increased CO2 production or decreased alveolar ventilation
Rationale: Acute hypercapnic respiratory failure occurs when the respiratory system cannot maintain normal CO2 levels due to increased CO2 production or decreased alveolar ventilation. The body’s inability to eliminate CO2 efficiently results in a buildup of CO2 in the bloodstream, leading to respiratory acidosis and impaired cellular function.
Which of the following factors can contribute to hypercapnic respiratory failure due to CNS problems?
A. Obstructive sleep apnea causing airway collapse
B. Chest wall deformities limiting lung expansion
C. Asthma causing airflow limitation and bronchoconstriction
D. Impaired respiratory drive from conditions like drug overdose or brain injury
D. Impaired respiratory drive from conditions like drug overdose or brain injury
Rationale: CNS problems such as drug overdose or brain injury can impair the brain’s ability to regulate the respiratory drive. This can decrease the body’s ability to stimulate appropriate ventilation, leading to hypercapnic respiratory failure. Conditions that reduce respiratory drive or affect the brainstem can hinder the body’s ability to expel CO2 properly.
A nurse is assessing a patient with hypercapnic respiratory failure caused by neuromuscular problems. Which of the following conditions would most likely contribute to this type of failure?
A. Pulmonary embolism leading to decreased ventilation
B. Chronic bronchitis leading to airway obstruction
C. Cerebral edema affecting brainstem function
D. Myasthenia gravis causing muscle weakness and impaired breathing
D. Myasthenia gravis causing muscle weakness and impaired breathing
Rationale: Neuromuscular problems like myasthenia gravis can impair the strength and function of respiratory muscles, including the diaphragm, leading to hypercapnic respiratory failure. The resulting weakness of respiratory muscles impairs the ability to ventilate the lungs effectively, preventing adequate elimination of CO2 from the body.
A patient with hypercapnic respiratory failure due to chest wall abnormalities is at risk for impaired ventilation. Which of the following would be the most likely cause of chest wall abnormalities in this patient?
A. Pneumonia causing alveolar inflammation
B. Obesity leading to upper airway obstruction
C. Kyphoscoliosis restricting chest expansion
D. Asthma exacerbation causing bronchospasm
C. Kyphoscoliosis restricting chest expansion
Rationale: Chest wall abnormalities, such as kyphoscoliosis, can severely restrict the expansion of the chest wall and lungs, limiting the ability to take deep breaths and effectively ventilate. This restriction leads to decreased alveolar ventilation, contributing to hypercapnic respiratory failure.
Which of the following would be an expected finding in a patient with hypercapnic respiratory failure caused by decreased alveolar ventilation?
A. Increased pCO2 levels and decreased oxygenation
B. Increased pO2 levels and normal pCO2 levels
C. Decreased pCO2 levels with normal pO2 levels
D. Normal pCO2 levels with decreased pO2 levels
A. Increased pCO2 levels and decreased oxygenation
Rationale: In hypercapnic respiratory failure, the primary issue is the inability to eliminate CO2 effectively, leading to an increase in pCO2 levels (respiratory acidosis). This impaired ventilation often also leads to decreased oxygenation, as the body cannot adequately exchange gases. Consequently, hypoxemia often accompanies hypercapnia.
Which of the following is the most common cause of hypercapnic respiratory failure in patients with normal lung function?
A. Airway obstruction caused by asthma or chronic obstructive pulmonary disease (COPD)
B. Acute pneumonia leading to inflammation and alveolar filling
C. Pulmonary embolism resulting in V/Q mismatch
D. Impaired ventilatory effort due to neuromuscular or CNS issues
D. Impaired ventilatory effort due to neuromuscular or CNS issues
Rationale: In patients with normal lung function, hypercapnic respiratory failure is most often caused by neuromuscular or CNS problems that impair the ventilatory effort. Conditions such as neuromuscular diseases (e.g., myasthenia gravis) or CNS dysfunction (e.g., brain injury or drug overdose) can reduce the ability of the respiratory muscles to function properly, leading to ventilatory failure and elevated CO2 levels.
A patient presents to the emergency department after an opioid overdose. The nurse is concerned about the risk of hypercapnic respiratory failure. Which of the following mechanisms is most likely contributing to this condition?
A. Increased CO2 production due to metabolic acidosis
B. Decreased CO2 reactivity in the brainstem due to opioid use
C. Increased alveolar ventilation from the opioid’s stimulating effects
D. Reduced perfusion of the lungs due to opioid-induced hypotension
B. Decreased CO2 reactivity in the brainstem due to opioid use
Rationale: Opioids are central nervous system depressants that decrease CO2 reactivity in the brainstem. This reduces the ability of the brainstem to detect increased CO2 levels in the blood, impairing the respiratory drive and leading to hypoventilation. As a result, CO2 levels rise, contributing to hypercapnic respiratory failure.
A patient with traumatic brain injury (TBI) is being monitored for respiratory function. Which of the following findings would indicate a risk for hypercapnic respiratory failure due to impaired CNS function?
A. Increased respiratory rate with normal PaCO2 levels
B. Normal respiratory rate with low PaCO2 levels
C. Decreased respiratory rate with elevated PaCO2 levels
D. Normal respiratory rate with elevated PaO2 levels
C. Decreased respiratory rate with elevated PaCO2 levels
Rationale: TBI can impair the function of the medullary respiratory center, which leads to a decreased ability to sense increased PaCO2 levels. This results in a decreased respiratory rate despite elevated PaCO2. This hypoventilation contributes to hypercapnic respiratory failure by preventing effective CO2 elimination.
A patient with a high-level spinal cord injury (SCI) presents with difficulty breathing. Which of the following is the most likely cause of hypercapnic respiratory failure in this patient?
A. Damage to the phrenic nerve leading to impaired diaphragm function
B. Increased metabolic demand due to high-energy consumption
C. Decreased alveolar ventilation due to impaired oxygen supply
D. Impaired blood flow to the lungs due to vascular injury
A. Damage to the phrenic nerve leading to impaired diaphragm function
Rationale: A high-level SCI can disrupt the phrenic nerve, which controls the diaphragm. Without adequate diaphragm function, the patient may struggle with effective ventilation, leading to hypercapnic respiratory failure. This is because the diaphragm is critical for inhalation and exhalation, and damage to the nerve impairs this process, preventing adequate CO2 elimination.
Which of the following is a likely consequence of a brainstem infarction affecting the respiratory centers in the medulla?
A. Improved response to increasing PaCO2 levels
B. Increased respiratory drive leading to hyperventilation
C. Enhanced cough reflex to manage airway secretions
D. Impaired ability to regulate respiratory rate in response to PaCO2 changes
D. Impaired ability to regulate respiratory rate in response to PaCO2 changes
Rationale: A brainstem infarction can impair the function of the respiratory centers in the medulla, which are responsible for regulating the respiratory rate in response to changes in PaCO2. This leads to a decreased respiratory drive and the inability to appropriately increase the rate of breathing in response to elevated CO2 levels, contributing to hypercapnic respiratory failure.
A nurse is assessing a patient who has experienced a traumatic brain injury (TBI). The patient is unresponsive and has impaired ability to manage secretions. What is the priority concern related to respiratory failure in this patient?
A. Impaired ability to clear secretions and protect the airway
B. Decreased O2 demand and ineffective ventilatory response
C. Increased CO2 clearance due to hyperventilation
D. Improved alveolar ventilation with higher oxygen levels
A. Impaired ability to clear secretions and protect the airway
Rationale: A patient with TBI and a decreased level of consciousness is at risk for aspiration and airway obstruction due to impaired cough reflex and inability to clear secretions. This increases the risk for respiratory failure, as blocked airways can impair gas exchange, leading to both hypoxemia and hypercapnia. Protecting the airway and ensuring proper ventilation are crucial for these patients.
A patient with opioid overdose is experiencing respiratory depression. Which of the following interventions is most appropriate to reverse the hypercapnic respiratory failure caused by CNS depression?
A. Administration of bronchodilators to improve airflow
B. Mechanical ventilation to support ventilation and oxygenation
C. Increased oxygen administration to improve CO2 clearance
D. Administration of naloxone to reverse the effects of the opioid
D. Administration of naloxone to reverse the effects of the opioid
Rationale: Naloxone, an opioid antagonist, is used to reverse the CNS depression caused by opioid overdose. By blocking the effects of the opioid on the brainstem, naloxone restores the respiratory drive, which is essential for the patient to regain normal ventilation and eliminate CO2 effectively, thus addressing the hypercapnic respiratory failure.
Which of the following is a significant risk for hypercapnic respiratory failure in patients with severe traumatic brain injury (TBI)?
A. Severe brain edema leading to compression of respiratory centers
B. Excessive ventilatory effort leading to hypoxia
C. Increased pain response causing hyperventilation
D. Alveolar collapse and atelectasis from decreased surfactant production
A. Severe brain edema leading to compression of respiratory centers
Rationale: Severe brain edema following TBI can lead to compression of the respiratory centers in the brainstem, impeding the brain’s ability to detect changes in PaCO2 and regulate ventilation accordingly. This results in hypoventilation, which prevents proper CO2 elimination, leading to hypercapnic respiratory failure.
A patient with Guillain-Barré syndrome is admitted to the hospital for respiratory support. Which of the following is the primary reason this patient is at risk for hypercapnic respiratory failure?
A. Impaired ventilation due to respiratory muscle paralysis
B. Decreased perfusion of the lungs due to systemic vasodilation
C. Increased metabolic demand leading to hyperventilation
D. Impaired gas exchange due to alveolar collapse
A. Impaired ventilation due to respiratory muscle paralysis
Rationale: Guillain-Barré syndrome causes ascending paralysis, which affects the respiratory muscles, including the diaphragm and intercostal muscles. As these muscles become weak or paralyzed, the patient cannot effectively ventilate the lungs, leading to an inability to eliminate CO2, which results in hypercapnic respiratory failure.
A nurse is caring for a patient with multiple sclerosis who is at risk for respiratory failure. Which of the following interventions is most important to monitor for in this patient?
A. Increased ventilatory drive due to severe hypoxia
B. Weakening of respiratory muscles and ineffective ventilation
C. Improved ventilation due to increased muscle strength
D. Elevated blood pressure due to hyperventilation
B. Weakening of respiratory muscles and ineffective ventilation
Rationale: Multiple sclerosis (MS) can cause muscle weakness, including respiratory muscles, which can impair the ability to ventilate effectively. As respiratory muscles weaken, the patient is at risk for hypoventilation, leading to the accumulation of CO2 and hypercapnic respiratory failure. Monitoring for respiratory muscle weakness and the ability to clear CO2 is critical in this patient population.
A patient with peripheral nerve damage secondary to critical illness is at risk for respiratory failure. Which of the following mechanisms is primarily responsible for this condition?
A. Increased CO2 production due to metabolic changes in the muscle cells
B. Impaired nerve supply to the respiratory muscles, leading to ineffective ventilation
C. Decreased pulmonary perfusion due to fluid overload
D. Hyperventilation causing an increase in PaCO2 levels
B. Impaired nerve supply to the respiratory muscles, leading to ineffective ventilation
Rationale: Peripheral nerve damage can disrupt the communication between the central nervous system and the respiratory muscles. This impairs the ability of the muscles to contract and function effectively, leading to ineffective ventilation. As a result, CO2 is not eliminated adequately, causing hypercapnic respiratory failure.
A patient who has been exposed to chemical nerve agents presents to the emergency department with signs of respiratory failure. Which of the following would most likely explain this patient’s respiratory distress?
A. Chemical agents causing respiratory muscle paralysis through disruption of nerve function
B. Chemical agents inducing bronchoconstriction and impaired airflow
C. Chemical agents increasing the body’s production of CO2
D. Chemical agents causing severe inflammation of the alveolar membrane
A. Chemical agents causing respiratory muscle paralysis through disruption of nerve function
Rationale: Chemical nerve agents, such as organophosphates, interfere with the nerve supply to respiratory muscles, causing muscle paralysis. This paralysis prevents adequate ventilation and the ability to clear CO2 from the lungs, leading to hypercapnic respiratory failure.
A nurse is monitoring a critically ill patient for signs of respiratory failure due to muscle wasting. What is the most important intervention to address this patient’s risk of respiratory failure?
A. Administering oxygen therapy to improve gas exchange
B. Increasing physical therapy to prevent further muscle wasting
C. Assessing respiratory muscle strength and ventilatory function
D. Initiating mechanical ventilation to support respiratory effort
C. Assessing respiratory muscle strength and ventilatory function
Rationale: Muscle wasting in critically ill patients can lead to respiratory muscle weakness, increasing the risk for respiratory failure. It is essential to assess respiratory muscle strength and monitor ventilatory function to detect early signs of hypoventilation and prevent hypercapnic respiratory failure. If muscle weakness is severe, mechanical ventilation may be required to support breathing.
A patient with severe obesity is admitted with respiratory distress. Which of the following explains why this patient may be at risk for ventilatory failure?
A. The inability to oxygenate blood due to alveolar collapse
B. Decreased lung compliance due to increased airway resistance
C. Increased oxygen demand from fat metabolism leading to hypoxia
D. Excessive weight on the chest and abdominal contents limits lung expansion
D. Excessive weight on the chest and abdominal contents limits lung expansion
Rationale: Severe obesity restricts lung expansion due to the increased weight of the chest and abdominal contents, particularly the abdomen, which presses up against the diaphragm. This decreases the available lung volume for gas exchange, increasing the risk of hypoventilation and ventilatory failure. The reduced expansion limits the ability to inhale deeply, which can result in poor oxygenation and hypercapnia.
A nurse is caring for a patient with flail chest. Which of the following findings is most likely in this patient?
A. Increased lung compliance with shallow breathing
B. Excessive chest wall expansion on inhalation
C. Decreased work of breathing due to rib fractures
D. Paradoxical chest movement during respiration
D. Paradoxical chest movement during respiration
Rationale: In flail chest, the rib fractures prevent normal chest expansion. The fractured segment of the chest wall moves paradoxically—it moves inward during inspiration and outward during expiration, opposite to the normal chest wall movement. This impairs ventilation and increases the work of breathing, contributing to hypoventilation and the risk of respiratory failure.
A patient with kyphosis is experiencing respiratory distress. Which of the following is the primary reason that kyphosis can lead to respiratory failure?
A. Spinal compression prevents normal lung expansion
B. Kyphosis increases airway resistance due to airway narrowing
C. Kyphosis leads to fluid accumulation in the alveoli, impairing gas exchange
D. Kyphosis causes a shift in lung tissue, decreasing lung volume
A. Spinal compression prevents normal lung expansion
Rationale: Kyphosis causes a change in spinal configuration that compresses the lungs, restricting chest wall expansion and reducing the ability of the lungs to expand fully during inspiration. This leads to impaired ventilation and hypoventilation, resulting in respiratory failure. The decreased lung expansion reduces the volume of air that can be inhaled, which contributes to hypoxemia and hypercapnia.
A nurse is assessing a patient with severe obesity for signs of ventilatory failure. Which of the following findings would be most concerning for this patient’s respiratory status?
A. Increased tidal volume during deep breathing
B. Use of accessory muscles with shallow breathing
C. Clear lung sounds with no sign of wheezing or crackles
D. Reduced work of breathing during rest
B. Use of accessory muscles with shallow breathing
Rationale: In severe obesity, the increased weight of the chest and abdominal contents can limit lung expansion. As a result, the patient may have shallow breathing and need to use accessory muscles to aid in ventilation. This increased work of breathing is a sign of respiratory distress and hypoventilation, indicating that the patient may be at risk for ventilatory failure. The inability to take deep breaths leads to insufficient gas exchange and possible hypoxemia and hypercapnia.
A patient with COPD is experiencing respiratory distress. What is the primary reason for the hypercapnic respiratory failure in this patient?
A. Increased airway resistance and air trapping in the alveoli
B. Decreased perfusion in the alveoli due to pulmonary embolism
C. Impaired gas exchange due to thickening of the alveolar-capillary membrane
D. Excessive oxygen consumption during metabolic processes
A. Increased airway resistance and air trapping in the alveoli
Rationale: In COPD, airway obstruction and air trapping in the alveoli occur due to chronic inflammation and narrowing of the airways. This leads to increased work of breathing and difficulty exhaling air from the lungs, which contributes to hypercapnia. The added work of breathing results in respiratory muscle fatigue and can ultimately lead to ventilatory failure, making it difficult for the patient to maintain adequate CO2 levels.
A nurse is assessing a patient with asthma who has a history of frequent bronchospasms. Which of the following is most likely to lead to hypercapnic respiratory failure in this patient?
A. Inflammation of the alveolar-capillary membrane, impairing gas exchange
B. Decreased perfusion of the alveoli due to an embolism
C. Airway obstruction and air trapping, increasing the work of breathing
D. Normal ventilation with limited diffusion of gases
C. Airway obstruction and air trapping, increasing the work of breathing
Rationale: In asthma, bronchospasm causes airway obstruction, which leads to air trapping in the lungs. The increased work of breathing (WOB) required to inspire air against increased airway resistance causes ventilatory failure. Over time, the patient may experience respiratory muscle fatigue as the muscles are overworked, resulting in hypercapnic respiratory failure due to the inability to effectively exhale CO2.
A nurse is caring for a patient with cystic fibrosis who is experiencing worsening respiratory distress. Which of the following is the most likely cause of hypercapnic respiratory failure in this patient?
A. Decreased blood flow to the lungs due to a pulmonary embolism
B. Impaired gas exchange due to thick mucus obstructing the airways
C. Alveolar hypoventilation from muscle weakness
D. Disruption of the alveolar-capillary membrane from fibrosis
B. Impaired gas exchange due to thick mucus obstructing the airways
Rationale: In cystic fibrosis, the accumulation of thick mucus in the airways leads to airway obstruction and impaired gas exchange. The mucus plugs block the flow of air and reduce the ability to exhale CO2, leading to hypercapnia. This significantly increases the work of breathing and can cause respiratory muscle fatigue, which eventually results in ventilatory failure.
A patient with COPD is receiving supplemental oxygen. Which of the following conditions increases the patient’s risk for hypercapnic respiratory failure?
A. Decreased oxygen demand during periods of rest
B. Improved airflow through bronchodilator therapy
C. Increased perfusion to the alveoli during oxygen therapy
D. Increased airway resistance and inability to adequately exhale air
D. Increased airway resistance and inability to adequately exhale air
Rationale: In COPD, there is increased airway resistance and air trapping in the lungs, which makes it difficult for the patient to exhale air effectively. This leads to an accumulation of CO2 in the blood, resulting in hypercapnic respiratory failure. Even with supplemental oxygen, if the patient cannot adequately exhale due to obstructed airways, respiratory muscle fatigue may occur, worsening the ventilatory failure. Oxygen therapy alone will not correct the underlying issue of airway obstruction.
A patient with COPD develops an upper respiratory tract infection. The nurse notes a gradual increase in the patient’s PaCO2 levels. Which of the following compensatory mechanisms is the body likely to use to mitigate the effects of hypercapnia?
A. Retention of bicarbonate by the kidneys
B. Increased alveolar ventilation to expel excess CO2
C. Activation of the sympathetic nervous system to increase heart rate
D. Increased excretion of carbonic acid through the kidneys
A. Retention of bicarbonate by the kidneys
Rationale: In cases of chronic hypercapnia, such as in COPD, the kidneys compensate by retaining bicarbonate (HCO3-) to buffer the excess CO2 in the blood. This compensatory mechanism helps maintain pH balance in the body by minimizing the acidic effects of increased CO2. This compensation occurs gradually, allowing the body to adapt to slow increases in PaCO2. Without treatment for the underlying cause, however, the patient may continue to worsen as the compensatory mechanisms reach their limit.
A nurse is caring for a patient with chronic respiratory failure who has been gradually developing an increase in PaCO2 levels. What is the primary reason the body can tolerate elevated CO2 levels better than low oxygen levels?
A. Hypoxia has a more immediate impact on cellular metabolism than hypercapnia
B. Hypercapnia stimulates the respiratory centers in the brain, improving ventilation
C. The body has more efficient mechanisms to compensate for CO2 retention
D. CO2 levels are easier to correct with supplemental oxygen therapy
C. The body has more efficient mechanisms to compensate for CO2 retention
Rationale: The body is generally more capable of compensating for increased CO2 levels than decreased oxygen levels. This is because slow, steady increases in PaCO2 allow the body time to compensate, mainly through renal retention of bicarbonate to buffer the acidity. On the other hand, hypoxemia (low O2 levels) does not have as much time to trigger compensatory mechanisms and can lead to more immediate and severe cellular dysfunction.
A patient with COPD presents with worsening respiratory distress due to an upper respiratory infection. The nurse understands that the body’s compensatory mechanisms for chronic hypercapnia may initially help maintain pH levels. What is the most likely effect of renal compensation in this patient?
A. Decreased bicarbonate excretion, leading to a more acidic pH
B. Increased excretion of bicarbonate, leading to alkalosis
C. Retention of bicarbonate to buffer the excess CO2 and maintain pH
D. Increased exhalation of CO2 to reduce PaCO2 levels
C. Retention of bicarbonate to buffer the excess CO2 and maintain pH
Rationale: When the body experiences chronic hypercapnia, such as in COPD, the kidneys compensate by retaining bicarbonate to buffer the excess CO2 and minimize changes in the arterial pH. This process helps maintain acid-base balance in the body and prevents the development of severe acidosis. Without correcting the underlying cause of the hypercapnia (e.g., the infection), however, this compensatory mechanism may eventually fail.
A patient with COPD experiences a rapid increase in PaCO2 levels following an upper respiratory infection. Which of the following interventions would be most beneficial in improving the patient’s condition?
A. Administering a diuretic to reduce fluid retention
B. Increased oxygen therapy to enhance ventilation
C. Identifying and treating the underlying cause of hypercapnia
D. Starting a high-dose corticosteroid to reduce inflammation
C. Identifying and treating the underlying cause of hypercapnia
Rationale: While oxygen therapy may help improve oxygenation in patients with hypercapnia, the most effective intervention is to identify and treat the underlying cause (e.g., infection, inflammation, or obstruction). Treating the primary cause of hypercapnia allows for correction of the condition, thus preventing worsening respiratory failure. In the case of COPD, treating the infection or inflammation would help alleviate the increased CO2 levels.
A nurse is educating a patient with COPD on the importance of controlling PaCO2 levels. The patient is informed that slow increases in PaCO2 can lead to compensatory mechanisms. What is the most accurate explanation for the body’s ability to tolerate chronic hypercapnia?
A. The lungs increase ventilation to expel CO2, preventing CO2 buildup
B. The brainstem adjusts to slow increases in CO2, leading to faster respiratory rates
C. The liver produces glucose to fuel metabolism during periods of hypoxia
D. The kidneys retain bicarbonate to buffer excess CO2, preventing severe acidosis
D. The kidneys retain bicarbonate to buffer excess CO2, preventing severe acidosis
Rationale: In response to chronic hypercapnia, such as in COPD, the kidneys compensate by retaining bicarbonate (HCO3-), which helps to buffer the excess CO2 and maintain a normal pH. This slow adjustment allows the body to tolerate higher levels of CO2 without immediate effects of acidosis. However, if the underlying cause is not treated, these compensatory mechanisms may eventually be overwhelmed, leading to respiratory failure.
A nurse is caring for a patient with COPD who presents with a gradual increase in PaCO2 due to an upper respiratory infection. Which of the following is the primary risk for this patient if the hypercapnia is not treated?
A. The patient will develop severe metabolic acidosis due to lactic acid buildup
B. The kidneys will lose the ability to retain bicarbonate, leading to worsening acidosis
C. The patient will experience worsening hypoxemia due to impaired gas exchange
D. The patient may experience worsening respiratory failure and tissue hypoxia
D. The patient may experience worsening respiratory failure and tissue hypoxia
Rationale: In chronic hypercapnia, such as in COPD, the body can initially compensate for increased CO2 by retaining bicarbonate to buffer the acid. However, if the underlying cause is not corrected (e.g., the upper respiratory infection), the patient may progress to worsening respiratory failure. Hypoxia and tissue dysfunction can occur as the body’s compensatory mechanisms become overwhelmed, leading to a decrease in oxygen supply to tissues. The risk of respiratory failure increases as the body cannot compensate effectively without treatment.
A nurse is caring for a patient diagnosed with hypoxemic respiratory failure (ARF) due to pulmonary embolism. Which of the following pathophysiological mechanisms most likely contributes to the patient’s condition?
A. V/Q mismatch and shunting
B. Hypercapnia from increased CO2 production
C. Toxic inhalation affecting alveolar ventilation
D. Decreased surfactant production in the alveoli
A. V/Q mismatch and shunting
Rationale: Pulmonary embolism commonly causes hypoxemic respiratory failure due to V/Q mismatch and shunting. The embolism obstructs pulmonary circulation, causing mismatched ventilation and perfusion, which leads to hypoxemia. Unlike hypercapnic failure, the issue in hypoxemic failure is primarily oxygenation, not CO2 retention.
A patient with chronic bronchitis is experiencing hypercapnic respiratory failure. Which of the following is the primary pathophysiological mechanism contributing to the development of this condition?
A. Damage to the respiratory center in the brainstem
B. Increased oxygen demand due to cardiac output changes
C. Airflow obstruction and air trapping
D. Decreased surfactant production leading to atelectasis
C. Airflow obstruction and air trapping
Rationale: In chronic bronchitis, airflow obstruction and air trapping due to increased mucus production and bronchial inflammation are the primary mechanisms causing hypercapnic respiratory failure. This results in ventilatory failure where the body cannot adequately eliminate CO2.
A patient is diagnosed with acute respiratory failure (ARF) due to pneumonia. Which of the following would be the most likely cause of hypoxemic respiratory failure in this patient?
A. V/Q mismatch and shunting from alveolar consolidation
B. Increased CO2 production due to systemic infection
C. Air trapping in obstructed airways leading to hypercapnia
D. Depressed respiratory drive due to CNS involvement
A. V/Q mismatch and shunting from alveolar consolidation
Rationale: In pneumonia, alveolar consolidation can lead to V/Q mismatch and shunting, preventing proper gas exchange and causing hypoxemic respiratory failure. Air trapping and hypercapnia are typically seen in obstructive lung diseases like COPD rather than in pneumonia.
Which of the following patients is at greatest risk for developing hypercapnic respiratory failure?
A. A 60-year-old patient with pulmonary embolism
B. A 70-year-old patient with pneumonia
C. A 45-year-old patient with severe obesity
D. A 35-year-old patient with acute asthma
C. A 45-year-old patient with severe obesity
Rationale: Severe obesity can lead to hypoventilation syndrome, where the overweight chest wall impairs lung expansion, making it difficult to eliminate CO2, leading to hypercapnic respiratory failure. While pulmonary embolism, pneumonia, and acute asthma are more commonly associated with hypoxemic respiratory failure, obesity is a primary risk factor for hypercapnia.
A patient is admitted with hypoxemic respiratory failure due to pulmonary edema. Which of the following pathophysiological mechanisms is most likely contributing to the patient’s condition?
A. Airway obstruction causing CO2 retention
B. Increased CO2 production from systemic acidosis
C. Impaired surfactant production leading to alveolar collapse
D. Fluid accumulation in the alveoli impairing gas exchange
D. Fluid accumulation in the alveoli impairing gas exchange
Rationale: In pulmonary edema, fluid accumulation in the alveoli interferes with gas exchange, leading to hypoxemic respiratory failure. This condition impairs the ability of oxygen to diffuse into the bloodstream and results in hypoxia. It does not primarily involve airway obstruction or CO2 retention as seen in hypercapnic failure.
A nurse is caring for a patient with COPD who is at risk for hypercapnic respiratory failure. Which of the following factors would most likely contribute to the patient’s difficulty in eliminating CO2?
A. Impaired ability to produce surfactant in the alveoli
B. V/Q mismatch leading to impaired oxygenation
C. Increased alveolar perfusion due to pulmonary hypertension
D. Increased work of breathing due to airflow obstruction
D. Increased work of breathing due to airflow obstruction
Rationale: In COPD, airflow obstruction causes increased work of breathing, which can lead to hypercapnic respiratory failure because the patient cannot adequately eliminate CO2. This is not due to impaired surfactant production or increased alveolar perfusion but rather the increased effort required to breathe against the obstructed airways.
A patient with neuromuscular disease develops hypercapnic respiratory failure. Which of the following underlying conditions would most likely contribute to ventilatory failure in this patient?
A. Impaired oxygen diffusion across the alveolar-capillary membrane
B. Weakness of respiratory muscles impeding CO2 elimination
C. Airway obstruction from mucus plugging in the bronchi
D. Increased CO2 production due to sepsis
B. Weakness of respiratory muscles impeding CO2 elimination
Rationale: In neuromuscular diseases such as Guillain-Barré syndrome or amyotrophic lateral sclerosis (ALS), weakness of the respiratory muscles impairs the ability to ventilate and eliminate CO2, leading to hypercapnic respiratory failure. This differs from conditions that primarily affect oxygen diffusion or airway patency.
Which of the following is the most common cause of hypoxemic respiratory failure in patients with pneumonia?
A. V/Q mismatch due to alveolar consolidation
B. Hypercapnia due to decreased ventilation
C. Severe airway obstruction causing air trapping
D. Impaired respiratory drive due to CNS depression
A. V/Q mismatch due to alveolar consolidation
Rationale: Pneumonia typically causes hypoxemic respiratory failure due to V/Q mismatch, where consolidation in the alveoli impairs gas exchange. This results in hypoxemia. It does not primarily cause hypercapnia or airway obstruction, which are associated with other conditions.
A patient with severe kyphoscoliosis is at risk for respiratory failure. Which of the following pathophysiological mechanisms is most likely contributing to this patient’s condition?
A. Airway obstruction and excessive mucus production
B. Increased alveolar perfusion and shunting
C. Impaired chest wall expansion leading to reduced ventilation
D. Loss of CNS drive to breathe
C. Impaired chest wall expansion leading to reduced ventilation
Rationale: Kyphoscoliosis causes abnormal spinal curvature, which limits chest wall expansion and impairs lung ventilation. This leads to hypoventilation and can contribute to respiratory failure. It does not directly involve airway obstruction, shunting, or loss of CNS respiratory drive.
A patient with pneumothorax develops hypoxemic respiratory failure. Which of the following mechanisms is most likely contributing to the development of respiratory failure in this patient?
A. Impaired ventilation and V/Q mismatch due to lung collapse
B. Increased CO2 retention due to airway obstruction
C. Decreased diffusion of oxygen due to pulmonary embolism
D. Increased alveolar perfusion without ventilation
A. Impaired ventilation and V/Q mismatch due to lung collapse
Rationale: Pneumothorax causes a collapse of the lung, impairing ventilation and leading to V/Q mismatch, which causes hypoxemic respiratory failure. This condition does not primarily result from CO2 retention or changes in alveolar perfusion.
A patient with muscular dystrophy is at risk for developing hypercapnic respiratory failure. What is the most likely contributing factor in this patient?
A. Increased V/Q mismatch due to airway obstruction
B. Impaired diffusion of oxygen across the alveolar membrane
C. Increased CO2 production from systemic infection
D. Weakness of respiratory muscles leading to inadequate ventilation
D. Weakness of respiratory muscles leading to inadequate ventilation
Rationale: Muscular dystrophy leads to weakness of respiratory muscles, which impairs the ability to ventilate effectively and eliminate CO2, leading to hypercapnic respiratory failure.
A 60-year-old patient with pulmonary edema is admitted with hypoxemic respiratory failure. Which of the following is the most likely cause of the patient’s condition?
A. Increased alveolar diffusion
B. V/Q mismatch and fluid accumulation in alveoli
C. Increased CO2 production leading to respiratory acidosis
D. Airway obstruction due to mucus plugging
B. V/Q mismatch and fluid accumulation in alveoli
Rationale: In pulmonary edema, fluid accumulates in the alveoli, impairing gas exchange and leading to V/Q mismatch, which is the primary cause of hypoxemic respiratory failure. The condition does not primarily involve increased CO2 production or airway obstruction.
A nurse is caring for a patient with severe obesity who is at risk for hypercapnic respiratory failure. Which of the following interventions is most important for managing this patient?
A. Administering high-flow oxygen
B. Encouraging the patient to sleep on their back
C. Monitoring for signs of airway obstruction
D. Promoting weight loss and using CPAP
D. Promoting weight loss and using CPAP
Rationale: In patients with severe obesity, hypoventilation syndrome can lead to hypercapnic respiratory failure. Continuous positive airway pressure (CPAP) helps improve ventilation and promoting weight loss can help reduce the risk of further respiratory issues. Simply using high-flow oxygen or encouraging back sleeping are not the most effective interventions for this specific condition.
A patient is diagnosed with neuromuscular disease and is experiencing hypercapnic respiratory failure. Which of the following factors contributes to the development of this condition in this patient?
A. Increased airway resistance due to inflammation
B. Weakness of respiratory muscles affecting CO2 elimination
C. Decreased alveolar perfusion from pulmonary embolism
D. Increased work of breathing due to airway obstruction
B. Weakness of respiratory muscles affecting CO2 elimination
Rationale: In neuromuscular diseases, weakness of respiratory muscles impairs the ability to adequately ventilate and eliminate CO2, leading to hypercapnic respiratory failure. This is distinct from conditions involving airway resistance or decreased alveolar perfusion, which are not typically the cause of hypercapnia in neuromuscular diseases.
A patient with acute respiratory failure (ARF) is admitted with a rapid rise in PaCO2. The nurse knows that this indicates:
A. Increased ability of the lungs to compensate
B. Severe respiratory compromise requiring urgent intervention
C. A gradual improvement in gas exchange
D. A normal compensatory response to hypoxia
B. Severe respiratory compromise requiring urgent intervention
Rationale: A rapid rise in PaCO2 suggests severe respiratory compromise, as the body cannot effectively eliminate CO2. This indicates the need for urgent intervention to address the underlying cause of respiratory failure and prevent life-threatening complications.
A patient with asthma develops severe bronchospasm, resulting in decreased airflow. The nurse understands that this leads to:
A. Respiratory muscle fatigue and acidemia
B. Increased oxygenation and rapid recovery
C. Excessive carbon dioxide elimination
D. Improvement in ventilation and perfusion ratio
A. Respiratory muscle fatigue and acidemia
Rationale: Severe bronchospasm in asthma leads to respiratory muscle fatigue due to the increased effort required to breathe. This, combined with impaired airflow, causes acidemia and can result in acute respiratory failure (ARF).
Which of the following clinical manifestations is most commonly associated with acute respiratory failure (ARF)?
A. Cyanosis
B. Increased levels of consciousness
C. Restlessness, confusion, and agitation
D. Decreased heart rate
C. Restlessness, confusion, and agitation
Rationale: Mental status changes, such as restlessness, confusion, and agitation, are often the first signs of hypoxemic ARF due to inadequate oxygenation of the brain. These signs typically occur before more severe manifestations, such as cyanosis.
A nurse is assessing a patient with hypoxemic respiratory failure. Which of the following signs indicates that the patient’s compensatory mechanisms are failing?
A. Tachycardia and tachypnea
B. Restlessness and confusion
C. Cyanosis and low oxygen saturation
D. Slight increase in work of breathing
C. Cyanosis and low oxygen saturation
Rationale: Cyanosis and low oxygen saturation are late signs of respiratory failure, indicating that the body’s compensatory mechanisms have failed to maintain adequate oxygenation. Tachycardia and tachypnea are early compensatory responses that occur before these more severe signs.
A patient with acute respiratory failure is exhibiting tachypnea and tachycardia. What does this indicate?
A. Inadequate compensation for respiratory failure
B. Attempts by the body to increase oxygen delivery
C. Improvement in gas exchange and perfusion
D. Worsening respiratory muscle fatigue
B. Attempts by the body to increase oxygen delivery
Rationale: Tachypnea and tachycardia are compensatory responses aimed at increasing oxygen delivery and eliminating CO2. These are early signs of respiratory failure as the body tries to compensate for declining oxygen levels and rising CO2.
Which of the following signs is most often associated with hypoxia in the early stages of acute respiratory failure (ARF)?
A. Cyanosis
B. Morning headache
C. Increased respiratory rate
D. Decreased work of breathing
C. Increased respiratory rate
Rationale: In the early stages of ARF, the body compensates for hypoxia by increasing the respiratory rate to enhance oxygen intake. Cyanosis is a late sign of ARF and does not occur until oxygen levels are critically low.
Which of the following is an unreliable indicator of hypoxemia in a patient with acute respiratory failure (ARF)?
A. Restlessness
B. Cyanosis
C. Tachypnea
D. Confusion
B. Cyanosis
Rationale: Cyanosis is a late sign of hypoxemia and is often unreliable as an early indicator of ARF. It typically does not appear until there is a significant decrease in oxygen saturation, often when deoxygenated hemoglobin concentration is around 5 g/dL.
Which of the following findings in a patient with respiratory failure is most concerning and requires immediate intervention?
A. Mild tachypnea with occasional confusion
B. Inability to lie flat due to severe dyspnea
C. Severe headache with normal mental status
D. Restlessness, agitation, and decreased O2 saturation
D. Restlessness, agitation, and decreased O2 saturation
Rationale: Restlessness and agitation in conjunction with decreased oxygen saturation indicate severe hypoxia and impaired oxygen delivery to the brain. This requires immediate intervention to prevent further deterioration and complications.
A nurse assesses a patient with severe COPD who is having difficulty breathing. The patient is in the tripod position. This position is commonly used to:
A. Increase the anteroposterior diameter of the chest
B. Promote relaxation of the respiratory muscles
C. Facilitate improved ventilation-perfusion matching
D. Assist in decreasing the need for oxygen therapy
A. Increase the anteroposterior diameter of the chest
Rationale: The tripod position is commonly used by patients with severe respiratory distress to increase the anteroposterior chest diameter, which helps to reduce the work of breathing (WOB) and improve ventilation. It is particularly beneficial for patients with COPD.
A nurse is observing a patient with respiratory failure in the tripod position. Which of the following is the nurse likely to observe?
A. The patient prefers lying flat to improve lung expansion
B. The patient is sitting with arms propped on the knees or table
C. The patient is lying with the head elevated to reduce WOB
D. The patient appears relaxed and free from dyspnea
B. The patient is sitting with arms propped on the knees or table
Rationale: In the tripod position, the patient sits upright with arms propped on the knees or an overbed table. This position helps to increase chest diameter and decrease thoracic pressure, easing the work of breathing (WOB) in patients with severe respiratory distress.
Which of the following is the most common cause of hypoxemic respiratory failure in patients with pneumonia?
A. Decreased lung compliance and impaired gas exchange
B. Increased CO2 production and impaired gas exchange
C. V/Q mismatch and impaired gas exchange
D. Elevated airway resistance and impaired gas exchange
C. V/Q mismatch and impaired gas exchange
Rationale: In pneumonia, inflammation and exudate in the alveoli lead to V/Q mismatch, where ventilation and perfusion are not balanced, causing impaired gas exchange and resulting in hypoxemic respiratory failure.
A patient with acute respiratory failure is found to be restless and agitated. The nurse understands that these symptoms are most likely due to:
A. Hypoxia and inadequate oxygenation
B. Excessive CO2 buildup and hypercapnia
C. Overuse of bronchodilators
D. Normal compensatory responses
A. Hypoxia and inadequate oxygenation
Rationale: Restlessness and agitation are often early signs of hypoxia in patients with respiratory failure, indicating inadequate oxygen delivery to the brain. These symptoms warrant immediate intervention to prevent further deterioration.
A patient with acute respiratory failure is being monitored for changes in mental status. Which of the following would be a priority for further assessment?
A. Improvement in alertness after oxygen administration
B. Confusion and agitation associated with worsening dyspnea
C. Drowsiness after a pain medication
D. Occasional forgetfulness
B. Confusion and agitation associated with worsening dyspnea
A patient with acute respiratory failure (ARF) presents with a rapid, shallow breathing pattern. The nurse understands that this may lead to:
A. Increased work of breathing and respiratory muscle fatigue
B. Improved gas exchange and oxygenation
C. Improved CO2 elimination and reduced hypercarbia
D. Decreased work of breathing and better respiratory muscle function
A. Increased work of breathing and respiratory muscle fatigue
Rationale: A rapid, shallow breathing pattern increases the work of breathing and can lead to respiratory muscle fatigue due to the high effort required for each breath, thus compromising the patient’s ability to effectively oxygenate and eliminate CO2.
A patient with acute asthma experiences a decrease in respiratory rate following initial rapid breathing. This change suggests:
A. Improvement in ventilation and oxygenation
B. Severe respiratory muscle fatigue and increased risk of respiratory arrest
C. Normal compensatory response to stress
D. A mild case of hypercapnia with no immediate concern
B. Severe respiratory muscle fatigue and increased risk of respiratory arrest
Rationale: A slower respiratory rate after initial rapid breathing in patients with acute asthma suggests severe respiratory muscle fatigue, which is an ominous sign of impending respiratory arrest due to the inability of the respiratory muscles to maintain adequate ventilation.
A patient experiencing dyspnea is able to speak only two words at a time before pausing to breathe. This indicates:
A. Mild respiratory distress with minimal risk
B. A normal response to physical exertion
C. Moderate to severe respiratory distress with impaired oxygenation
D. Improvement in oxygenation and reduced work of breathing
C. Moderate to severe respiratory distress with impaired oxygenation
Rationale: “Two-word dyspnea” indicates that the patient is experiencing significant respiratory distress, with limited ability to speak due to impaired oxygenation. This signifies moderate to severe distress, requiring prompt intervention to prevent worsening.
A patient in acute respiratory failure (ARF) is using pursed-lip breathing. The nurse recognizes that this technique:
A. Increases SaO2 by slowing respirations and preventing bronchiolar collapse
B. Is ineffective and may worsen dyspnea
C. Promotes rapid shallow breathing and increased work of breathing
D. Causes a decrease in oxygenation and gas exchange
A. Increases SaO2 by slowing respirations and preventing bronchiolar collapse
Rationale: Pursed-lip breathing helps slow respiration and increases time for expiration, which prevents small bronchioles from collapsing. This technique improves SaO2 and reduces the work of breathing, which is helpful for patients with obstructive lung conditions like ARF.
A nurse observes retraction of the intercostal spaces in a patient with respiratory distress. This finding suggests:
A. Mild respiratory distress with normal work of breathing
B. Severe respiratory distress with increased work of breathing
C. Improvement in ventilation and oxygenation
D. A normal compensatory mechanism in ARF
B. Severe respiratory distress with increased work of breathing
Rationale: Retraction of the intercostal spaces indicates the use of accessory muscles and suggests severe respiratory distress. It indicates an increased work of breathing (WOB) and requires immediate attention to prevent further deterioration.
A patient exhibits paradoxical breathing. The nurse understands that this finding suggests:
A. A mild degree of respiratory distress
B. A normal breathing pattern with no concern
C. Severe respiratory distress and maximal use of accessory muscles
D. Improvement in respiratory function with better gas exchange
C. Severe respiratory distress and maximal use of accessory muscles
Rationale: Paradoxical breathing occurs in severe respiratory distress when the abdomen and chest move in opposite directions. This pattern results from maximal use of accessory muscles, indicating significant difficulty in breathing and a need for urgent intervention.
A patient in acute respiratory failure is noted to be diaphoretic with increased work of breathing. This finding is most likely related to:
A. Hypercapnia and respiratory muscle fatigue
B. Effective compensation for oxygenation and CO2 removal
C. Low blood pressure due to hypovolemia
D. Improvement in oxygenation due to increased heart rate
A. Hypercapnia and respiratory muscle fatigue
Rationale: Diaphoresis in the context of increased work of breathing indicates hypercapnia (elevated CO2) and respiratory muscle fatigue, both of which can occur during acute respiratory failure as the body struggles to compensate for inadequate ventilation.
During auscultation, the nurse hears fine crackles in a patient with acute respiratory failure. This finding is most likely associated with:
A. Pulmonary edema
B. Pneumothorax
C. Atelectasis
D. Asthma exacerbation
A. Pulmonary edema
Rationale: Fine crackles are often heard in patients with pulmonary edema, indicating the presence of fluid in the alveoli. This can impair gas exchange and contribute to the development of acute respiratory failure.
The nurse auscultates coarse crackles on expiration in a patient with acute respiratory failure. This is suggestive of:
A. Fluid in the airways, potentially due to pneumonia or heart failure
B. Airway constriction and increased resistance
C. Clear lung fields with no underlying pathology
D. Bronchospasm in a patient with asthma
A. Fluid in the airways, potentially due to pneumonia or heart failure
Rationale: Coarse crackles on expiration are indicative of fluid in the airways, commonly associated with pneumonia or heart failure. This fluid impairs ventilation and can lead to hypoxemia and acute respiratory failure.
A nurse hears bronchial breath sounds over the lung periphery in a patient with pneumonia. This indicates:
A. Normal lung sounds
B. Airway obstruction from a foreign body
C. Air trapping in the alveoli
D. Consolidation of the lung tissue
D. Consolidation of the lung tissue
Rationale: Bronchial breath sounds heard over the periphery of the lungs are abnormal and typically indicate lung consolidation, which occurs in conditions like pneumonia, where alveolar spaces fill with fluid or exudate, leading to impaired gas exchange.
A nurse is assessing a patient with acute respiratory failure. The presence of a pleural friction rub on auscultation is indicative of:
A. Infection involving the pleura, such as pneumonia
B. Airway obstruction due to foreign body aspiration
C. Pulmonary embolism
D. Emphysema with increased lung compliance
A. Infection involving the pleura, such as pneumonia
Rationale: A pleural friction rub is often heard when the pleura is inflamed, as seen in pneumonia or other infections that involve the pleura. This sound occurs when the inflamed pleural layers rub against each other during respiration.
Which of the following findings in a patient with acute respiratory failure would most likely require immediate intervention?
A. Fine crackles heard at the bases of the lungs
B. Retraction of the intercostal spaces and use of accessory muscles
C. Absent breath sounds in the left lower lobe
D. Paradoxical breathing pattern with increased WOB
D. Paradoxical breathing pattern with increased WOB
Rationale: Paradoxical breathing is a sign of severe respiratory distress and requires immediate intervention. It indicates maximal use of accessory muscles and a failure of normal respiratory mechanics, which can rapidly progress to respiratory failure.
A nurse is caring for a patient with acute respiratory failure. The patient has absent or decreased breath sounds in the lower lobes. This finding suggests:
A. Atelectasis, pleural effusion, or hypoventilation
B. Pneumonia or pulmonary edema
C. Normal breath sounds in the lower lobes
D. Bronchospasm or bronchitis
A. Atelectasis, pleural effusion, or hypoventilation
Rationale: Absent or decreased breath sounds in the lower lobes are often associated with atelectasis, pleural effusion, or hypoventilation. These conditions impair lung expansion and contribute to acute respiratory failure.
A nurse is reviewing the diagnostic studies ordered for a patient with suspected acute respiratory failure (ARF). Which of the following diagnostic studies is most commonly used to evaluate oxygenation and ventilation status?
A. 12-lead ECG
B. Chest x-ray
C. ABG analysis
D. Pulse oximetry
C. ABG analysis
Rationale: ABG analysis is the most common diagnostic tool to evaluate both oxygenation (PaO2) and ventilation (PaCO2), as well as acid-base balance (pH and bicarbonate). This provides crucial information for assessing the severity of ARF.
A patient with acute respiratory failure (ARF) has a chest x-ray showing signs of atelectasis. The nurse understands that this result indicates:
A. Complete obstruction of the airway
B. Collapsed lung tissue, impairing gas exchange
C. Lung consolidation due to pneumonia
D. Infection causing airway inflammation
B. Collapsed lung tissue, impairing gas exchange
Rationale: Atelectasis refers to the collapse of lung tissue, leading to impaired gas exchange and potential development of ARF. This condition can obstruct airflow and compromise ventilation, causing hypoxemia.
A patient with suspected pulmonary embolism (PE) is undergoing a CT scan. The nurse understands that the CT scan is ordered to:
A. Assess oxygenation status and ABG values
B. Identify structural abnormalities such as atelectasis or pneumonia
C. Detect a pulmonary embolism or other blockages in the pulmonary vasculature
D. Evaluate heart function and electrical activity
C. Detect a pulmonary embolism or other blockages in the pulmonary vasculature
Rationale: A CT scan is commonly used to detect a pulmonary embolism (PE), which can cause acute respiratory failure by blocking pulmonary blood flow. It is particularly helpful in identifying emboli that may not be visible on a chest x-ray.
Which diagnostic study would most likely be ordered for a patient with severe ARF requiring mechanical ventilation to assess ventilation trends?
A. End-tidal CO2 (EtCO2) measurement
B. Complete blood cell count (CBC)
C. Pulse oximetry
D. 12-lead ECG
A. End-tidal CO2 (EtCO2) measurement
Rationale: End-tidal CO2 (EtCO2) is used to assess ventilation trends in patients requiring mechanical ventilation. It provides real-time feedback on how effectively CO2 is being eliminated from the body.
A patient with suspected infection has blood and sputum cultures ordered. What is the primary purpose of these cultures in the management of ARF?
A. To identify the presence of a bacterial or viral infection
B. To determine the need for mechanical ventilation
C. To assess the extent of atelectasis or lung collapse
D. To evaluate electrolyte imbalances
A. To identify the presence of a bacterial or viral infection
Rationale: Blood and sputum cultures (including Gram stain, culture, and sensitivity) are used to identify infections, which are common causes of ARF. They help guide appropriate antibiotic therapy and address the underlying infectious cause.
A nurse is reviewing the diagnostic studies for a patient in ARF. Which of the following is the most useful for continuously monitoring a patient’s oxygenation status?
A. ABG analysis
B. Pulse oximetry
C. 12-lead ECG
D. Urinalysis
B. Pulse oximetry
Rationale: Pulse oximetry is a non-invasive and continuous method to monitor oxygen saturation (SaO2), providing real-time information about a patient’s oxygenation status. It is particularly useful for ongoing assessment in patients with ARF.
A patient’s ABG results show a low PaO2 and elevated PaCO2. The nurse interprets these findings as indicative of:
A. Adequate ventilation and oxygenation
B. Hyperventilation and respiratory alkalosis
C. Hypoventilation and respiratory acidosis
D. Normal respiratory function
C. Hypoventilation and respiratory acidosis
Rationale: Low PaO2 (indicating hypoxemia) and elevated PaCO2 (indicating hypoventilation) are characteristic of respiratory acidosis. This is commonly seen in ARF where ventilation is inadequate to eliminate CO2 and maintain oxygenation.
A nurse is reviewing the results of a complete blood cell count (CBC) for a patient with suspected ARF. Which of the following CBC findings would be most indicative of an infection as the underlying cause of ARF?
A. Low white blood cell count (WBC)
B. Normal hemoglobin and hematocrit levels
C. Low platelet count
D. Elevated WBC count
D. Elevated WBC count
Rationale: An elevated white blood cell count (WBC) is a common indicator of infection, which may contribute to ARF. Infections such as pneumonia or sepsis can trigger the inflammatory response, leading to impaired ventilation and oxygenation.
A nurse is caring for a patient with acute respiratory failure (ARF) in a high-acuity unit. The health care team is discussing the management plan. Which of the following factors most significantly influences the initial management strategy for ARF?
A. Patient’s blood pressure
B. Patient’s age and underlying comorbidities
C. Presence of electrolyte imbalances
D. Results of ABG analysis
B. Patient’s age and underlying comorbidities
Rationale: The initial management of ARF is tailored based on patient-specific factors such as age, underlying comorbidities, and the severity and cause of respiratory failure. This allows for personalized treatment strategies that address the root cause and patient’s needs.
In a patient with mild to moderate ARF, the nurse anticipates that the initial treatment will likely include:
A. Non-invasive positive pressure ventilation
B. Mechanical ventilation with endotracheal intubation
C. Continuous IV sedation
D. Blood transfusion
A. Non-invasive positive pressure ventilation
Rationale: In patients with mild to moderate ARF, non-invasive positive pressure ventilation (e.g., BiPAP) may be used, especially if the patient is alert, able to maintain a patent airway, and can clear their own secretions. This method supports oxygenation and ventilation without the need for invasive intubation.
A patient in severe ARF is admitted to the ICU and is placed on mechanical ventilation. The nurse understands that which of the following is a priority in monitoring the patient?
A. Central venous pressure (CVP)
B. Arterial blood pressure (ABP) only
C. Serum electrolytes
D. Pulse oximetry and ABG analysis
D. Pulse oximetry and ABG analysis
Rationale: In severe ARF, monitoring of pulse oximetry and frequent ABG analysis is critical to assess oxygenation, ventilation, and acid-base balance. These parameters guide adjustments in mechanical ventilation and other treatments.
A nurse is assessing a patient with ARF in the ICU who is receiving mechanical ventilation. The health care team decides to use central venous O2 saturation (SvO2) monitoring. What is the primary purpose of this intervention?
A. To monitor heart rate and rhythm
B. To assess the adequacy of tissue perfusion and response to treatment
C. To measure blood volume and electrolyte imbalances
D. To evaluate lung function during mechanical ventilation
B. To assess the adequacy of tissue perfusion and response to treatment
Rationale: Central venous O2 saturation (SvO2) provides information about tissue perfusion and the balance between oxygen delivery and consumption. It helps assess how well the body is responding to interventions aimed at improving oxygenation and circulation in ARF patients.
In a patient with severe ARF, the nurse understands that which of the following monitoring parameters is NOT typically used for assessing the patient’s cardiac function?
A. Central venous pressure (CVP)
B. Ejection fraction (EF)
C. Pulmonary capillary wedge pressure (PCWP)
D. Oxygen saturation (SpO2)
D. Oxygen saturation (SpO2)
Rationale: While SpO2 is essential for monitoring oxygenation, ejection fraction, CVP, and PCWP are used to assess cardiac function and hemodynamics, particularly in patients with severe ARF requiring intensive care. Oxygen saturation (SpO2) is not specific to cardiac function.
Which of the following actions is most important for the nurse when caring for a patient with ARF in the ICU receiving mechanical ventilation?
A. Maintain a sterile environment around the intubation site
B. Administer sedatives to prevent discomfort
C. Ensure adequate fluid intake
D. Monitor central venous pressure (CVP) regularly
A. Maintain a sterile environment around the intubation site
Rationale: Maintaining a sterile environment around the intubation site is crucial to prevent ventilator-associated pneumonia and other infections. It is a priority for infection control in patients on mechanical ventilation.
A patient with ARF is receiving high-flow oxygen therapy via an Optiflow device. The nurse should prioritize monitoring for:
A. Signs of oxygen toxicity and hypercapnia
B. Increased respiratory rate and tachycardia
C. Electrolyte imbalances
D. Signs of increased work of breathing (WOB)
A. Signs of oxygen toxicity and hypercapnia
Rationale: High-flow oxygen therapy can potentially cause oxygen toxicity and hypercapnia, especially in patients with underlying COPD or other conditions that impair CO2 removal. Close monitoring for these complications is important.
A nurse is preparing to monitor a patient in severe ARF using advanced hemodynamic monitoring. Which of the following parameters is NOT typically assessed by this monitoring technique?
A. Cardiac output (CO)
B. Pulmonary capillary wedge pressure (PCWP)
C. Central venous oxygen saturation (SvO2)
D. Serum potassium levels
D. Serum potassium levels
Rationale: Advanced hemodynamic monitoring focuses on cardiac output (CO), pulmonary capillary wedge pressure (PCWP), and central venous oxygen saturation (SvO2) to assess circulatory status and tissue perfusion. Serum potassium levels are not part of this specific monitoring.
In a patient with severe ARF, the nurse understands that the goal of mechanical ventilation is to:
A. Increase respiratory rate and decrease CO2
B. Eliminate all need for sedatives
C. Ensure that oxygen delivery meets the patient’s metabolic demands
D. Minimize the need for diuretics
C. Ensure that oxygen delivery meets the patient’s metabolic demands
Rationale: The primary goal of mechanical ventilation is to support the patient’s respiratory function by ensuring that oxygen delivery is adequate to meet the patient’s metabolic demands, especially in the context of ARF, where the lungs cannot maintain adequate gas exchange on their own.
A nurse is assessing a patient with acute respiratory failure (ARF). The nurse understands that the priority assessment for this patient should be:
A. Assessing the patient’s ability to maintain a patent airway and breathe
B. Monitoring for signs of gastrointestinal distress
C. Assessing the patient’s level of hydration
D. Determining the patient’s emotional response to the diagnosis
A. Assessing the patient’s ability to maintain a patent airway and breathe
Rationale: The priority assessment in a patient with ARF is to evaluate their ability to maintain a patent airway and adequate ventilation. This ensures that the patient is able to oxygenate properly and removes CO2, which is essential in managing respiratory failure.
Which of the following factors should the nurse closely monitor in a patient with preexisting cardiac and/or respiratory disease to detect early signs of respiratory and hemodynamic decompensation?
A. Pulse oximetry and ABG trends
B. Patient’s body weight and fluid intake
C. Fever and blood pressure fluctuations
D. Bowel movements and abdominal tenderness
A. Pulse oximetry and ABG trends
Rationale: Pulse oximetry and ABG trends are critical tools for monitoring oxygenation and ventilation status, particularly in patients with preexisting cardiac and respiratory disease. Subtle changes in these parameters can indicate the onset of respiratory or hemodynamic decompensation.
In the assessment of a patient with ARF, which of the following is a subtle sign that may indicate worsening hypoxemia or hypercarbia?
A. Increased respiratory rate
B. Tachycardia and elevated blood pressure
C. Changes in level of consciousness
D. Skin pallor and increased urinary output
C. Changes in level of consciousness
Rationale: Changes in level of consciousness are a subtle sign of worsening hypoxemia or hypercarbia. This is because the brain is highly sensitive to changes in oxygen and carbon dioxide levels. Mental status changes such as restlessness, confusion, or agitation may indicate inadequate oxygen delivery to the brain.
What is the most appropriate action for the nurse if subtle changes in pulse oximetry or ABGs indicate early signs of respiratory failure in a patient?
A. Wait for the next scheduled ABG to confirm the trend
B. Notify the healthcare provider (HCP) immediately
C. Increase the patient’s oxygen flow rate
D. Administer sedatives to reduce anxiety
B. Notify the healthcare provider (HCP) immediately
Rationale: If subtle changes in pulse oximetry or ABGs suggest worsening respiratory failure, the nurse must notify the healthcare provider immediately to initiate timely interventions, prevent further deterioration, and improve patient outcomes.
A nurse is assessing a patient with acute respiratory failure (ARF). Which of the following is most important to evaluate when assessing the patient’s response to therapy?
A. Temperature and urinary output
B. Trend in ABGs and pulse oximetry
C. Electrolyte levels and fluid balance
D. Level of sedation and comfort
B. Trend in ABGs and pulse oximetry
Rationale: The trend in ABGs and pulse oximetry provides the best measure of the patient’s oxygenation and ventilation status, which is essential for evaluating their response to therapy and adjusting treatment accordingly.
When caring for a patient with acute respiratory failure (ARF), which of the following assessments would the nurse perform to detect early respiratory insufficiency?
A. Monitor blood pressure and serum glucose levels
B. Assess for signs of peripheral edema and dehydration
C. Perform a thorough respiratory assessment including breath sounds
D. Observe for changes in the patient’s nutritional intake
C. Perform a thorough respiratory assessment including breath sounds
Rationale: A thorough respiratory assessment, including auscultating breath sounds, helps in detecting early signs of respiratory insufficiency. This includes identifying abnormal sounds such as crackles or wheezes, which may indicate worsening conditions like pulmonary edema or bronchospasm.
A nurse is monitoring a patient with acute respiratory failure (ARF) and observes a sudden decrease in PaO2. Which of the following actions should the nurse take next?
A. Increase the oxygen delivery rate and assess the patient’s response
B. Administer a sedative to calm the patient
C. Call for a STAT chest x-ray to evaluate for atelectasis
D. Place the patient in a high Fowler’s position and recheck vitals
A. Increase the oxygen delivery rate and assess the patient’s response
Rationale: A sudden decrease in PaO2 suggests an acute respiratory problem, and the nurse should immediately increase the oxygen delivery rate while assessing the patient’s response to therapy. Prompt adjustments are necessary to prevent further deterioration.
In a patient with acute respiratory failure (ARF), the nurse should be most concerned with which of the following changes when monitoring trends in ABGs?
A. Increased PaCO2 levels
B. Decreased PaO2 levels
C. Increased bicarbonate levels
D. Decreased pH levels
B. Decreased PaO2 levels
Rationale: A decreased PaO2 level indicates worsening hypoxemia, a key feature of acute respiratory failure. This is a critical change that requires immediate attention and intervention to restore adequate oxygenation.
A nurse is assessing a patient with hypoxemia and observes intercostal muscle retraction and nasal flaring. Which of the following best describes these findings?
A. Nonspecific signs of respiratory distress
B. Specific signs of hypercapnia
C. Late manifestations of hypoxemia
D. Early indicators of metabolic acidosis
C. Late manifestations of hypoxemia
Rationale: Intercostal muscle retraction and nasal flaring are specific signs that indicate severe hypoxemia. These are often observed in late stages as the body struggles to maintain adequate oxygen levels.
In a patient with hypoxemia, the nurse notices a decrease in SpO2 levels to below 90%. What does this indicate?
A. Early stage of oxygen deprivation
B. Severe oxygen deprivation and impending respiratory failure
C. Normal physiological response to exercise
D. Normal variation in oxygen saturation
B. Severe oxygen deprivation and impending respiratory failure
Rationale: SpO2 levels below 90% indicate severe hypoxemia, which can lead to respiratory failure if not corrected promptly. This is a critical finding requiring immediate intervention.
Which of the following is a late manifestation of hypercapnia?
A. Morning headache
B. Cyanosis
C. Tachypnea
D. Increased BP
A. Morning headache
Rationale: A morning headache is a late manifestation of hypercapnia. It results from increased CO2 levels in the blood, which can lead to vasodilation and increased pressure in the cranial cavity.
A patient with hypoxemia is displaying agitation, confusion, and restlessness. These symptoms are most indicative of:
A. Severe acid-base imbalances
B. A normal response to increased respiratory effort
C. Early signs of hypoxia affecting the central nervous system
D. Progression to respiratory failure
C. Early signs of hypoxia affecting the central nervous system
Rationale: Agitation, confusion, and restlessness are often early manifestations of hypoxia affecting the central nervous system (CNS). These symptoms reflect inadequate oxygen supply to the brain.
A nurse is assessing a patient who exhibits tripod positioning and pursed-lip breathing. These findings are most commonly associated with which condition?
A. Hypercapnia
B. Metabolic acidosis
C. Hypoxemia
D. Acute pain syndrome
A. Hypercapnia
Rationale: Tripod positioning and pursed-lip breathing are commonly observed in patients with hypercapnia as they attempt to facilitate better airflow and reduce the work of breathing, improving gas exchange.
A patient with hypercapnia exhibits muscle weakness and tremors. Which of the following is the nurse’s best course of action?
A. Administer a sedative to reduce the tremors
B. Increase the patient’s oxygen supply to correct respiratory acidosis
C. Prepare for potential mechanical ventilation due to respiratory failure
D. Monitor the patient’s neurological status for further changes
D. Monitor the patient’s neurological status for further changes
Rationale: Muscle weakness and tremors are neurological signs of hypercapnia. The nurse should continue to monitor for progression and ensure that the patient is closely observed for increased somnolence or coma, which are late signs of hypercapnia.
A patient with hypoxemia develops tachypnea, and the nurse notes that the patient’s blood pressure is elevated early on. Which of the following does this combination of symptoms most likely indicate?
A. Severe acute respiratory distress syndrome (ARDS)
B. Progressive metabolic acidosis
C. Compensatory response to decreased oxygen levels
D. Non-cardiac related systemic hypertension
C. Compensatory response to decreased oxygen levels
Rationale: Tachypnea and elevated BP are compensatory mechanisms in response to hypoxemia, as the body tries to increase oxygen intake and perfusion to vital organs. However, if the condition worsens, blood pressure may drop in the late stages.
Which of the following is a late manifestation of hypoxemia that could indicate the need for immediate intervention?
A. Restlessness and confusion
B. Tachycardia and hypertension
C. Cyanosis and decreased level of consciousness
D. Fatigue and inability to speak in full sentences
C. Cyanosis and decreased level of consciousness
Rationale: Cyanosis and decreased level of consciousness are late manifestations of hypoxemia, signifying severe oxygen deprivation. Immediate intervention is needed to prevent respiratory failure.
In a patient with hypercapnia, which of the following findings indicates the progression toward severe respiratory failure?
A. Elevated blood pressure
B. Increased deep tendon reflexes
C. Shallow respirations and tachycardia
D. Progressive somnolence and increased ICP
D. Progressive somnolence and increased ICP
Rationale: Progressive somnolence and increased intracranial pressure (ICP) are late signs of hypercapnia, indicating worsening respiratory function and the risk of respiratory failure. These changes necessitate urgent intervention.
A nurse is caring for a patient who is dyspneic and has decreased tidal volume and shallow respirations. These findings are most indicative of:
A. Hypercapnia and respiratory acidosis
B. Hyperkalemia and respiratory alkalosis
C. Hypoxemia and metabolic alkalosis
D. Cardiogenic shock and decreased perfusion
A. Hypercapnia and respiratory acidosis
Rationale: Decreased tidal volume and shallow respirations are indicative of hypercapnia, which leads to respiratory acidosis due to insufficient CO2 removal. This can be a sign of respiratory failure.
A patient with hypoxemia is found to have cool, clammy, and diaphoretic skin. This finding is most concerning because it indicates:
A. Severe oxygen deprivation and shock
B. Infection and a potential fever
C. Neurological compromise from hypercapnia
D. A compensatory response to hypovolemia
A. Severe oxygen deprivation and shock
Rationale: Cool, clammy, and diaphoretic skin is a sign of severe hypoxemia and the body’s attempt to compensate for inadequate oxygen supply. It also suggests that the patient may be entering shock.
A nurse is assessing a patient with hypoxemia and observes paradoxical chest or abdominal wall movement. This finding is most likely indicative of:
A. Mild respiratory distress
B. Severe respiratory distress and impending failure
C. Normal compensation for increased respiratory effort
D. Acute myocardial infarction and ischemia
B. Severe respiratory distress and impending failure
Rationale: Paradoxical chest or abdominal wall movement is a late sign of severe respiratory distress and can occur when the patient’s respiratory muscles become fatigued and unable to maintain normal breathing patterns, indicating impending respiratory failure.
A patient with hypercapnia exhibits seizures. Which of the following is the most likely cause?
A. Severe acidosis and electrolyte disturbances
B. Hypovolemia causing cerebral ischemia
C. Severe hypoxia and inadequate oxygen delivery to the brain
D. Increased cerebrovascular pressure due to elevated CO2 levels
D. Increased cerebrovascular pressure due to elevated CO2 levels
Rationale: Seizures in patients with hypercapnia are typically due to increased cerebrovascular pressure, as elevated CO2 levels can cause vasodilation of cerebral blood vessels, leading to increased intracranial pressure and neurological symptoms such as seizures.
A nurse is developing a care plan for a patient with acute respiratory failure (ARF). Which of the following is the most important goal to include in the plan of care for this patient?
A) The patient will maintain a pulse oximetry reading of 90% or greater.
B) The patient will independently maintain a patent airway.
C) The patient will demonstrate the ability to speak in full sentences.
D) The patient will maintain normal blood pressure levels.
B) The patient will independently maintain a patent airway.
Rationale: The most important goal for a patient with ARF is to ensure that the patient can independently maintain a patent airway, as this is critical for preventing further respiratory compromise.
A 72-year-old male with a history of COPD presents with worsening dyspnea and hypoxemia. His ABG results are as follows: pH 7.32, PaCO2 50 mmHg, PaO2 55 mmHg, and HCO3 24 mEq/L. Which of the following is the most appropriate short-term goal for the patient’s care?
A) The patient will improve ABG values to normal limits within 48 hours.
B) The patient will effectively clear secretions within 24 hours.
C) The patient will maintain a patent airway and restore baseline oxygenation levels.
D) The patient will demonstrate the ability to perform controlled coughing techniques within 2 hours.
C) The patient will maintain a patent airway and restore baseline oxygenation levels.
Rationale: The immediate priority for this patient is to maintain a patent airway and restore baseline oxygenation to prevent further deterioration. Other goals like controlled coughing or clearing secretions are important but secondary in this acute phase.
A nurse is monitoring a patient with ARF in the ICU. Which of the following nursing interventions is most appropriate to help the patient achieve the goal of independently maintaining a patent airway?
A) Administering a sedative to reduce agitation.
B) Encouraging the patient to perform deep breathing exercises.
C) Monitoring the patient for signs of respiratory distress and providing supplemental oxygen as needed.
D) Placing the patient in a lateral position to promote comfort.
C) Monitoring the patient for signs of respiratory distress and providing supplemental oxygen as needed.
Rationale: Monitoring for signs of respiratory distress and providing supplemental oxygen helps ensure the patient can maintain a patent airway, which is essential in ARF management.
Which of the following outcomes would indicate the successful achievement of the goal for a patient with ARF to “effectively cough and clear secretions”?
A) The patient demonstrates the ability to cough independently.
B) The patient maintains a respiratory rate of 12-16 breaths per minute.
C) The patient has a clear chest upon auscultation.
D) The patient can speak in full sentences without pausing to breathe..
A) The patient demonstrates the ability to cough independently.
Rationale: The ability to cough independently is a direct indicator that the patient can effectively clear secretions, which is a key goal for those with ARF to prevent further respiratory complications.
A nurse is caring for a patient at high risk for acute respiratory failure (ARF) due to COPD. Which of the following interventions should the nurse prioritize to prevent ARF in this patient?
A) Administering high doses of antibiotics to prevent infection.
B) Encouraging early ambulation and teaching deep breathing exercises.
C) Increasing the patient’s fluid intake to maintain hydration.
D) Limiting oxygen therapy to prevent CO2 retention.
B) Encouraging early ambulation and teaching deep breathing exercises.
Rationale: For patients at high risk of ARF, preventive strategies like early ambulation and teaching deep breathing exercises can help reduce the risk of complications such as atelectasis and pneumonia, which are common causes of ARF.
A patient with a history of neuromuscular disease is hospitalized for pneumonia. The nurse is assessing the patient for signs of ARF. Which of the following is the most effective action to prevent ARF in this patient?
A) Administering prophylactic antibiotics for pneumonia.
B) Performing frequent position changes and encouraging incentive spirometry.
C) Restricting fluid intake to prevent fluid overload.
D) Teaching the patient how to manage pain effectively.
B) Performing frequent position changes and encouraging incentive spirometry.
Rationale: Frequent position changes and the use of incentive spirometry can help prevent atelectasis and pneumonia, which are important strategies for preventing ARF in patients with neuromuscular or respiratory issues.
A nurse is assessing a patient at risk for ARF. Which of the following findings is a priority for the nurse to address in this patient’s care plan?
A) Respiratory rate of 14 breaths per minute.
B) Elevated blood pressure and pulse.
C) Recent weight loss of 5 pounds over the past week.
D) Mild crackles heard in the lower lung fields on auscultation.
D) Mild crackles heard in the lower lung fields on auscultation.
Rationale: Mild crackles in the lower lung fields may indicate early signs of atelectasis or fluid accumulation, which are risk factors for ARF. Addressing this early through interventions like deep breathing exercises or incentive spirometry can help prevent further deterioration.
A nurse is teaching a patient at risk for ARF about preventive measures. Which of the following statements by the patient indicates a need for further teaching?
A) “I will try to ambulate as soon as possible after surgery.”
B) “I will use the incentive spirometer every hour while awake.”
C) “I should avoid coughing because it might irritate my lungs.”
D) “I will make sure to drink plenty of fluids to stay hydrated.”
C) “I should avoid coughing because it might irritate my lungs.”
Rationale: Coughing is a vital protective mechanism for clearing secretions and preventing complications such as pneumonia. The patient should be taught the importance of coughing to prevent respiratory failure, not avoid it.
A nurse is caring for a patient with COPD to prevent ARF. Which of the following is the most important action the nurse can take?
A) Administering corticosteroids as ordered to reduce airway inflammation.
B) Monitoring oxygen saturation levels regularly.
C) Teaching the patient to use the incentive spirometer every hour.
D) Encouraging the patient to rest in a supine position to improve oxygenation.
C) Teaching the patient to use the incentive spirometer every hour.
Rationale: Incentive spirometry is an essential tool in preventing atelectasis and improving lung expansion, especially in patients with COPD, who are at high risk for ARF due to airway obstruction and impaired gas exchange.
A nurse is caring for a post-surgical patient at risk for ARF. Which of the following preventive interventions should be prioritized for this patient to reduce the risk of respiratory complications?
A) Encouraging hourly incentive spirometry use and frequent position changes.
B) Administering analgesics to prevent pain-induced hypoventilation.
C) Administering oxygen therapy to maintain an SpO2 greater than 95%.
D) Ensuring the patient is placed in the Trendelenburg position to optimize ventilation.
A) Encouraging hourly incentive spirometry use and frequent position changes.
Rationale: Encouraging the use of the incentive spirometer and frequent position changes helps prevent atelectasis and pneumonia, which are critical preventive measures for patients at risk for ARF.
Which of the following is an effective preventive measure for a patient at risk for ARF due to immobility?
A) Keeping the patient in a supine position to reduce the risk of aspiration.
B) Limiting fluid intake to prevent fluid overload.
C) Placing the patient in the lateral position to prevent pressure ulcers.
D) Encouraging early and frequent ambulation to promote lung expansion.
D) Encouraging early and frequent ambulation to promote lung expansion.
Rationale: Early and frequent ambulation is essential in preventing respiratory complications, including ARF, especially for patients who are immobile and at high risk for atelectasis and pneumonia.
A nurse is caring for a patient with acute respiratory failure (ARF) who is being treated for a V/Q mismatch. Which of the following interventions should the nurse prioritize to improve oxygenation and ventilation?
A) Administering supplemental oxygen to increase the oxygen supply.
B) Positioning the patient with the head of the bed flat to improve ventilation.
C) Administering diuretics to decrease fluid buildup in the lungs.
D) Monitoring for signs of respiratory alkalosis and adjusting ventilator settings.
A) Administering supplemental oxygen to increase the oxygen supply.
Rationale: For patients with V/Q mismatch, supplemental oxygen is essential to improve oxygenation and ventilation. Oxygen therapy helps correct the mismatch between ventilation and perfusion, improving overall oxygen delivery.
A nurse is caring for a patient with ARF due to diffusion impairment. The nurse is monitoring the patient’s ABGs for signs of clinical improvement. Which of the following ABG trends would indicate improvement in the patient’s oxygenation status?
A) Decrease in PaO2 and increase in PaCO2.
B) Increase in pH and PaCO2 levels.
C) Increase in PaO2 and decrease in PaCO2.
D) Decrease in pH with a stable PaO2 level.
C) Increase in PaO2 and decrease in PaCO2.
Rationale: An increase in PaO2 and a decrease in PaCO2 indicate improved oxygenation and ventilation, which is essential in treating diffusion impairment in ARF. This shows better gas exchange and clinical improvement.
A nurse is caring for a patient with ARF and is closely monitoring for clinical improvement. Which of the following assessments would be most useful to evaluate the effectiveness of the current treatment plan?
A) Monitoring for changes in the patient’s level of consciousness.
B) Checking for temperature fluctuations and assessing for fever.
C) Evaluating the patient’s daily weight to check for fluid retention.
D) Assessing for improvement in respiratory rate and ABG values.
D) Assessing for improvement in respiratory rate and ABG values.
Rationale: Monitoring the patient’s respiratory rate and trends in ABG values is essential in assessing the effectiveness of interventions aimed at improving oxygenation and ventilation in ARF. These parameters directly reflect the patient’s respiratory status and response to treatment.
Which of the following interventions is most appropriate for a patient with ARF caused by shunting, based on the underlying pathophysiology?
A) Administering high-flow oxygen therapy to improve oxygen supply.
B) Encouraging deep breathing and coughing exercises to improve ventilation.
C) Positioning the patient in the lateral decubitus position to improve perfusion.
D) Providing mechanical ventilation with positive end-expiratory pressure (PEEP) to improve oxygenation.
D) Providing mechanical ventilation with positive end-expiratory pressure (PEEP) to improve oxygenation.
Rationale: For patients with ARF caused by shunting, PEEP is often used in mechanical ventilation to improve oxygenation by preventing alveolar collapse and improving oxygen exchange, which addresses the mismatch in ventilation and perfusion.
A nurse is caring for a patient with ARF secondary to a V/Q mismatch. The nurse notes that the patient is exhibiting increasing signs of respiratory distress despite the administration of supplemental oxygen. What is the nurse’s next priority action?
A) Increase the oxygen flow rate and observe for further changes.
B) Assess the patient for signs of worsening hypoxemia and notify the healthcare provider.
C) Increase the dose of bronchodilators and continue oxygen therapy.
D) Begin mechanical ventilation immediately to support respiratory function.
B) Assess the patient for signs of worsening hypoxemia and notify the healthcare provider.
Rationale: If the patient is not responding to supplemental oxygen and is showing signs of worsening respiratory distress, it is crucial to assess for worsening hypoxemia and notify the healthcare provider for further intervention. This may require additional therapies or adjustments to the treatment plan.
A nurse is caring for a patient with ARF due to a diffusion impairment. The patient’s ABG results show a PaO2 of 50 mmHg and a PaCO2 of 55 mmHg. What is the nurse’s priority intervention?
A) Administer a bronchodilator and assess for airway obstruction.
B) Encourage deep breathing and coughing to improve ventilation.
C) Increase oxygen therapy and prepare for potential intubation.
D) Position the patient upright and encourage fluid intake to improve gas exchange.
C) Increase oxygen therapy and prepare for potential intubation.
Rationale: For a patient with a diffusion impairment and significantly low PaO2 and high PaCO2, increasing oxygen therapy and preparing for intubation is crucial to support ventilation and oxygenation. This intervention addresses the impaired gas exchange caused by diffusion issues in ARF.
A nurse is caring for a patient receiving respiratory therapy to maintain adequate oxygenation and ventilation. Which of the following interventions is most appropriate to correct an acid-base imbalance in this patient?
A) Administering sodium bicarbonate to correct metabolic acidosis.
B) Increasing the oxygen flow rate to improve oxygenation and ventilation.
C) Using a humidifier to prevent mucus dryness and mobilize secretions.
D) Implementing positive pressure ventilation to improve CO2 removal.
D) Implementing positive pressure ventilation to improve CO2 removal.
Rationale: Positive pressure ventilation can help improve CO2 removal, which is crucial for correcting acid-base imbalances, particularly in cases of respiratory acidosis. It supports ventilation by helping to expel CO2, improving the patient’s overall acid-base status.
A nurse is caring for a patient in respiratory failure who requires respiratory therapy. The nurse is planning interventions to mobilize secretions and improve oxygenation. Which of the following interventions should the nurse include in the care plan?
A) Administering high-flow oxygen therapy and encouraging deep breathing.
B) Applying positive pressure ventilation and using an incentive spirometer.
C) Administering a bronchodilator and encouraging the patient to cough and deep breathe.
D) Increasing the oxygen flow rate and preparing the patient for intubation.
C) Administering a bronchodilator and encouraging the patient to cough and deep breathe.
Rationale: Administering a bronchodilator can help open the airways, making it easier for the patient to cough and clear secretions. This is an important step in improving oxygenation and mobilizing secretions effectively.
A patient with respiratory failure is receiving oxygen therapy, and the healthcare team is monitoring for improvement in ventilation and oxygenation. Which of the following outcomes would indicate that the respiratory therapy is effectively meeting the patient’s needs?
A) The patient is able to speak in full sentences without pausing to breathe.
B) The patient shows no signs of tachypnea or labored breathing.
C) The patient’s PaCO2 levels remain elevated despite oxygen therapy.
D) The patient’s ABG shows normal oxygen levels but low CO2 levels.
A) The patient is able to speak in full sentences without pausing to breathe.
Rationale: The ability to speak in full sentences without pausing to breathe indicates improved oxygenation and ventilation, demonstrating the effectiveness of the respiratory therapy in maintaining adequate oxygenation.
A nurse is administering oxygen therapy to a patient with acute respiratory failure. What is the primary goal of oxygen therapy in this patient?
A) Reduce CO2 retention and prevent hypercapnia.
B) Correct hypoxemia while using the lowest effective FiO2.
C) Increase alveolar nitrogen levels to maintain structural integrity.
D) Maintain a PaCO2 level below 35 mm Hg.
B) Correct hypoxemia while using the lowest effective FiO2.
Rationale: The goal of oxygen therapy is to correct hypoxemia while administering the lowest FiO2 needed to maintain adequate oxygenation, thereby reducing the risk of oxygen toxicity.
A patient receiving oxygen therapy via face mask for severe hypoxemia is restless and repeatedly tries to remove the mask. What is the nurse’s best action?
A) Secure the mask tightly with straps to prevent removal.
B) Assess for signs of worsening hypoxemia and explore alternative oxygen delivery options.
C) Decrease the FiO2 to 21% and encourage the patient to breathe deeply.
D) Switch to a simple nasal cannula at 2 L/min.
B) Assess for signs of worsening hypoxemia and explore alternative oxygen delivery options.
Rationale: Restlessness and agitation can be signs of worsening hypoxemia. The nurse should assess the patient’s respiratory status and consider alternative delivery devices that ensure adequate oxygenation while minimizing anxiety.
A mechanically ventilated patient requires high FiO2 levels. The nurse recognizes that prolonged exposure to FiO2 >60% for more than 48 hours increases the risk for:
A) Oxygen toxicity.
B) Metabolic acidosis.
C) Decreased alveolar CO2 retention.
D) Respiratory alkalosis.
A) Oxygen toxicity.
Rationale: High concentrations of oxygen for extended periods can lead to oxygen toxicity, causing alveolar damage, inflammation, and cellular death.
A patient with chronic hypercapnia from COPD is started on oxygen therapy. What is the nurse’s primary concern?
A) The patient may develop respiratory depression due to a blunted CO2 response.
B) The patient’s lungs will become fibrotic from high oxygen concentrations.
C) The patient will hyperventilate due to excessive oxygenation.
D) The patient’s carbon dioxide levels will immediately return to normal.
A) The patient may develop respiratory depression due to a blunted CO2 response.
Rationale: In patients with chronic hypercapnia, high oxygen levels can blunt the respiratory drive, leading to respiratory depression.
Which of the following complications can result from prolonged exposure to high FiO2? Select all that apply.
A) Oxygen toxicity
B) Absorption atelectasis
C) Decreased pulmonary capillary permeability
D) Increased surfactant production
E) Fibrotic changes in the alveoli
A) Oxygen toxicity
B) Absorption atelectasis
E) Fibrotic changes in the alveoli
Rationale: High FiO2 levels can lead to oxygen toxicity, alveolar collapse due to nitrogen displacement (absorption atelectasis), and long-term fibrotic changes in lung tissue.
A patient with acute respiratory failure is receiving oxygen therapy. The nurse determines that the patient is improving based on which finding?
A) The patient’s SpO2 remains below 85%.
B) The patient has a PaO2 of 55 mm Hg.
C) The patient’s PaO2 trends toward 60 mm Hg or higher.
D) The patient’s respiratory rate has increased to 35 breaths per minute.
C) The patient’s PaO2 trends toward 60 mm Hg or higher.
Rationale: A PaO2 of 60 mm Hg or higher indicates improved oxygenation.
A patient with COPD is receiving oxygen via nasal cannula at 2 L/min but remains hypoxemic. What is the nurse’s next best action?
A) Increase the oxygen flow rate to 6 L/min.
B) Administer bronchodilators to improve ventilation.
C) Discontinue oxygen therapy to prevent CO2 retention.
D) Change to a Venturi mask delivering 24%-28% FiO2.
D) Change to a Venturi mask delivering 24%-28% FiO2.
Rationale: A Venturi mask provides precise oxygen concentrations, making it ideal for COPD patients to prevent excessive oxygen delivery and CO2 retention.
A patient receiving high-flow oxygen therapy begins experiencing increasing dyspnea, confusion, and cyanosis. What should the nurse suspect?
A) The patient is experiencing oxygen toxicity.
B) The patient is not responding to oxygen therapy and may need mechanical ventilation.
C) The patient is developing metabolic alkalosis.
D) The patient is experiencing nitrogen washout syndrome.
B) The patient is not responding to oxygen therapy and may need mechanical ventilation.
Rationale: If a patient remains hypoxemic despite high-flow oxygen, mechanical ventilation may be required.
Which finding indicates that a patient with ARF is experiencing absorption atelectasis due to prolonged high FiO2 exposure?
A) Presence of pleural friction rub.
B) Decreased breath sounds and new-onset hypoxemia.
C) Increased pulmonary compliance.
D) Hyperinflation of alveoli.
B) Decreased breath sounds and new-onset hypoxemia.
Rationale: Absorption atelectasis occurs when nitrogen is displaced by oxygen, leading to alveolar collapse, decreased breath sounds, and worsening hypoxemia.
A patient with ARF is receiving oxygen therapy via a non-rebreather mask. The nurse observes that the reservoir bag fully collapses with each breath. What is the appropriate intervention?
A) Decrease the oxygen flow rate to ensure adequate reservoir filling.
B) Switch to a Venturi mask to ensure adequate reservoir filling.
C) Increase the oxygen flow rate to ensure adequate reservoir filling.
D) Remove the mask and use a nasal cannula instead to ensure adequate reservoir filling.
C) Increase the oxygen flow rate to ensure adequate reservoir filling.
Rationale: The reservoir bag should not fully collapse; increasing the oxygen flow rate ensures proper oxygen delivery.
A patient is receiving 70% FiO2 for more than 48 hours. The nurse monitors for which complication?
A) Pulmonary hypertension and alveolar damage
B) Surfactant inactivation and alveolar damage
C) Decreased CO2 retention and alveolar damage
D) Increased airway resistance and alveolar damage
B) Surfactant inactivation and alveolar damage
Rationale: Prolonged exposure to high oxygen concentrations can lead to decreased surfactant production, alveolar injury, and fibrosis.
A patient receiving oxygen therapy suddenly becomes agitated and confused. What is the nurse’s priority action?
A) Check ABG results for worsening hypoxemia.
B) Lower the oxygen flow rate immediately.
C) Encourage deep breathing and coughing.
D) Discontinue oxygen therapy.
A) Check ABG results for worsening hypoxemia.
Rationale: Agitation and confusion can indicate worsening hypoxemia, requiring immediate assessment.
A nurse is caring for a patient on oxygen therapy who develops new-onset muscle twitching and dizziness. The nurse suspects:
A) Hypercapnia
B) Oxygen toxicity
C) Metabolic acidosis
D) Atelectasis
B) Oxygen toxicity
Rationale: Oxygen toxicity can cause neurological symptoms such as muscle twitching and dizziness due to excess oxygen radicals.
A nurse is preparing to initiate oxygen therapy for a patient with suspected ARF. What should be the nurse’s initial action?
A) Assess the patient’s respiratory status and ABG values.
B) Start high-flow oxygen at 100% FiO2.
C) Apply a nasal cannula at 6 L/min.
D) Position the patient supine for comfort.
A) Assess the patient’s respiratory status and ABG values.
Rationale: A full assessment is essential to determine appropriate oxygen therapy.
Which of the following patients would benefit most from a Venturi mask?
A) A patient with ARF requiring precise oxygen delivery.
B) A patient with suspected pulmonary embolism.
C) A patient with an acute asthma attack.
D) A patient requiring immediate intubation.
A) A patient with ARF requiring precise oxygen delivery.
Rationale: Venturi masks provide precise oxygen concentrations, making them ideal for patients requiring controlled oxygenation.
A nurse is caring for a patient with acute respiratory failure (ARF) who has thick pulmonary secretions. Which intervention is most effective in mobilizing these secretions?
A) Administering high-flow oxygen therapy at 100% FiO2
B) Encouraging adequate hydration and providing humidified oxygen
C) Keeping the patient in a supine position to conserve energy
D) Restricting fluid intake to prevent pulmonary edema
B) Encouraging adequate hydration and providing humidified oxygen
Rationale: Hydration and humidified oxygen therapy help thin and mobilize secretions, making it easier for the patient to clear them.
A patient with ARF is experiencing difficulty clearing thick respiratory secretions despite frequent coughing. The nurse anticipates implementing which additional intervention?
A) Placing the patient in a high-Fowler’s position and performing chest physiotherapy
B) Restricting fluids to reduce secretion production
C) Increasing oxygen flow to 10 L/min via nasal cannula
D) Administering a sedative to reduce coughing effort
A) Placing the patient in a high-Fowler’s position and performing chest physiotherapy
Rationale: Positioning and chest physiotherapy (e.g., postural drainage, percussion, vibration) promote secretion mobilization and clearance.
A mechanically ventilated patient with ARF has coarse breath sounds and decreasing oxygen saturation despite adequate ventilator settings. What is the nurse’s priority intervention?
A) Increase the FiO2 to improve oxygenation
B) Administer a diuretic to decrease pulmonary congestion
C) Perform endotracheal suctioning to remove retained secretions
D) Place the patient in a Trendelenburg position to improve secretion drainage
C) Perform endotracheal suctioning to remove retained secretions
Rationale: Coarse breath sounds and decreased oxygen saturation suggest secretion retention, which can impair gas exchange. Suctioning is necessary to remove secretions and improve oxygenation.
A patient with ARF is unable to effectively cough up secretions despite being alert and cooperative. The nurse should prioritize which intervention?
A) Encourage deep breathing and use of an incentive spirometer
B) Administer a muscle relaxant to decrease respiratory effort
C) Discontinue fluid intake to prevent further secretion buildup
D) Reduce oxygen flow rate to prevent overoxygenation
A) Encourage deep breathing and use of an incentive spirometer
Rationale: Incentive spirometry and deep breathing exercises promote lung expansion and secretion mobilization, helping to prevent complications such as atelectasis.
A patient with acute respiratory failure (ARF) is experiencing dyspnea and hypoxemia. Which positioning intervention should the nurse implement first?
A) Place the patient in a supine position to conserve energy
B) Position the patient in a Trendelenburg position
C) Encourage the patient to lie flat to improve ventilation
D) Elevate the head of the bed to at least 30 degrees
D) Elevate the head of the bed to at least 30 degrees
Rationale: Elevating the head of the bed promotes lung expansion, decreases dyspnea, and enhances oxygenation, which is essential in managing ARF.
A patient with left-sided pneumonia is experiencing hypoxemia despite oxygen therapy. The nurse should reposition the patient in which way to optimize ventilation and perfusion?
A) Right side-lying position (good lung down)
B) Left side-lying position (affected lung down)
C) Supine position with the head of the bed flat
D) Prone position with arms extended above the head
A) Right side-lying position (good lung down)
Rationale: Placing the patient in a lateral position with the “good lung down” maximizes ventilation-perfusion (V/Q) matching and improves oxygenation.
A patient with ARF has bilateral lung involvement and is struggling to clear secretions. What is the nurse’s best intervention to optimize ventilation and secretion clearance?
A) Keep the patient in a supine position to minimize oxygen demand
B) Reposition the patient regularly from side to side
C) Place the patient in a high-Fowler’s position and avoid movement
D) Encourage the patient to stay in one lateral position for an extended time
B) Reposition the patient regularly from side to side
Rationale: Regular repositioning helps mobilize secretions, optimize air movement, and improve overall oxygenation, especially in patients with bilateral lung involvement.
A nurse is repositioning a patient with ARF who is at risk for aspiration. Which position is most appropriate?
A) Trendelenburg position
B) Side-lying position
C) Supine with head flat
D) Prone position
B) Side-lying position
Rationale: A side-lying position reduces the risk of aspiration by preventing secretions from pooling in the airway.
A patient with acute respiratory distress is seated in a chair but continues to experience dyspnea. What additional positioning intervention should the nurse implement?
A) Have the patient lean slightly forward while sitting
B) Ask the patient to recline completely in the chair
C) Place the patient in a low-Fowler’s position
D) Encourage the patient to lie in a supine position with pillows under the knees
A) Have the patient lean slightly forward while sitting
Rationale: A forward-leaning position, such as the tripod position, promotes better diaphragm movement and reduces work of breathing.
The nurse is caring for a patient with ARF who is intubated and mechanically ventilated. To optimize oxygenation, which positioning strategy is most effective?
A) Positioning the patient in a prone position
B) Keeping the patient in a flat supine position
C) Placing the patient in a semi-Fowler’s position only
D) Avoiding any repositioning to prevent accidental extubation
A) Positioning the patient in a prone position
Rationale: Prone positioning can improve oxygenation by promoting alveolar recruitment and better ventilation-perfusion matching, particularly in patients with ARF related to ARDS.
A patient with right-sided pneumonia requires frequent suctioning. To optimize secretion drainage, the nurse should place the patient in which position?
A) Left side-lying
B) Right side-lying
C) Supine with the head of the bed at 15 degrees
D) Prone with the head of the bed at 45 degrees
A) Left side-lying
Rationale: The “good lung down” position (left side-lying for right-sided pneumonia) promotes secretion drainage from the affected lung and enhances ventilation in the healthier lung.
A patient with ARF is experiencing worsening hypoxemia despite oxygen therapy. The healthcare provider orders “good lung down” positioning. What is the expected outcome of this intervention?
A) Increased secretion retention due to gravity-dependent pooling
B) Decreased oxygenation due to limited lung expansion
C) Increased cardiac output due to better venous return
D) Improved oxygenation due to enhanced ventilation-perfusion matching
D) Improved oxygenation due to enhanced ventilation-perfusion matching
Rationale: Placing the “good lung down” improves ventilation and perfusion, which enhances oxygenation in patients with unilateral lung disease.
A nurse is teaching a patient with acute respiratory failure (ARF) how to perform huff coughing. Which statement by the patient indicates correct understanding?
A. “I should take a deep breath, hold it for a few seconds, and then forcefully exhale while saying ‘huff.’”
B. “I should breathe in deeply, hold my breath, and then cough as hard as possible to clear my lungs.”
C. “I should lean forward while coughing to increase airway clearance.”
D. “I should breathe in and out through my nose while coughing to clear secretions.”
A. “I should take a deep breath, hold it for a few seconds, and then forcefully exhale while saying ‘huff.’”
Rationale: Huff coughing is a technique that keeps the glottis open while expelling air, reducing airway collapse and making secretion clearance more effective. The patient should take a deep breath, hold it briefly, and then exhale forcefully while saying “huff.” This method is particularly beneficial for patients with conditions like COPD.
A 67-year-old patient with chronic obstructive pulmonary disease (COPD) and recent pneumonia is experiencing difficulty clearing thick secretions. The nurse observes weak coughing efforts and diminished breath sounds in the lower lobes. The patient states, “I feel like I can’t get the mucus out, no matter how hard I try.”
What is the best intervention for the nurse to perform?
A. Encourage the patient to drink 500 mL of water quickly.
B. Position the patient in the Trendelenburg position to drain secretions.
C. Instruct the patient to hold their breath for 10 seconds before coughing forcefully.
D. Instruct the patient to perform huff coughing.
D. Instruct the patient to perform huff coughing.
Rationale: Huff coughing is an effective technique for patients with COPD and retained secretions. It generates sufficient airflow without causing excessive fatigue, preventing airway collapse while clearing mucus.
A critically ill patient in the ICU is receiving mechanical ventilation and has copious pulmonary secretions. The nurse notes that the patient’s SpO₂ has decreased from 96% to 89%, and rhonchi are auscultated bilaterally. What should the nurse do first?
A. Perform suctioning to remove secretions.
B. Encourage augmented coughing.
C. Increase the ventilator’s oxygen delivery.
D. Place the patient in the prone position.
A. Perform suctioning to remove secretions.
Rationale: In a mechanically ventilated patient with worsening oxygenation and audible secretions, immediate suctioning is required to remove mucus and improve gas exchange. Augmented coughing is ineffective for an intubated patient, and increasing FiO₂ does not address the underlying issue.
A nurse is teaching a postoperative patient how to perform a staged cough. Which statement by the patient indicates further teaching is needed?
A. “I should take three to four deep breaths before coughing.”
B. “I should press a pillow against my abdomen while coughing.”
C. “I should lie flat in bed while performing this technique.”
D. “I should lean forward slightly when coughing.”
C. “I should lie flat in bed while performing this technique.”
Rationale: The staged cough is most effective when the patient is in a sitting position, which promotes better lung expansion and secretion clearance. Lying flat may impair diaphragmatic movement and increase the risk of aspiration.
The nurse is assisting a patient with quadriplegia to perform augmented coughing. Which technique is most appropriate?
A. Encouraging the patient to inhale deeply and then cough forcefully.
B. Applying firm pressure at the anterolateral base of the lungs during exhalation.
C. Positioning the patient in a left side-lying position before coughing.
D. Providing chest physiotherapy before instructing the patient to cough.
B. Applying firm pressure at the anterolateral base of the lungs during exhalation.
Rationale: Augmented coughing (quad coughing) involves applying firm pressure to the anterolateral base of the patient’s lungs during exhalation to help generate sufficient force for secretion clearance. This technique is useful for patients with weak respiratory muscles.
A patient in the ICU with ARF is unable to clear thick secretions despite multiple attempts at coughing. The nurse anticipates which order from the provider?
A. Increase IV fluid intake to promote secretion thinning.
B. Administer bronchodilators and mucolytics.
C. Encourage the patient to perform huff coughing more frequently.
D. Change the patient’s position to supine to facilitate secretion drainage.
B. Administer bronchodilators and mucolytics.
Rationale: Mucolytics help break down thick secretions, making them easier to clear, while bronchodilators open airways, facilitating secretion movement. Increased fluid intake may help long-term, but immediate pharmacologic intervention is often required in critical patients.
A nurse is teaching a COPD patient about techniques to clear pulmonary secretions. Which technique is most appropriate?
A. Holding the breath for 10 seconds before coughing.
B. Using rapid shallow breaths before coughing.
C. Performing huff coughing to clear the airways.
D. Coughing with full force to expel secretions quickly.
C. Performing huff coughing to clear the airways.
Rationale: Huff coughing prevents airway collapse by keeping the glottis open, making it the preferred method for COPD patients to clear secretions effectively.
A 50-year-old patient recovering from pneumonia states, “I feel like I can’t get all the mucus out when I cough.” The nurse observes weak coughing efforts and notes coarse crackles in the lung bases. What intervention should the nurse perform first?
A. Encourage the patient to drink more fluids.
B. Administer albuterol nebulizer treatment.
C. Obtain a sputum culture.
D. Teach the patient augmented coughing techniques.
D. Teach the patient augmented coughing techniques.
Rationale: Augmented coughing helps patients with weak respiratory muscles generate enough force to expel secretions. Increasing fluids may help long-term, but immediate intervention is needed. An albuterol nebulizer would be used for bronchospasms rather than secretion clearance.
A nurse is performing chest physiotherapy (CPT) on a patient with pneumonia. Which action is most appropriate to facilitate secretion clearance?
A. Position the patient with the affected lung down.
B. Perform percussion and vibration over the affected lung segments.
C. Encourage the patient to breathe rapidly before coughing.
D. Limit postural drainage to 5 minutes per session to prevent fatigue.
B. Perform percussion and vibration over the affected lung segments.
Rationale: Percussion and vibration help mobilize secretions by loosening mucus from the airways. These techniques allow secretions to move toward larger airways, where they can be removed by coughing or suctioning.
A 68-year-old patient with chronic bronchitis and severe atelectasis has been prescribed chest physiotherapy (CPT). The nurse reviews the patient’s history and notes a recent diagnosis of a traumatic brain injury (TBI) with increased intracranial pressure (ICP).
Which action should the nurse take?
A. Proceed with CPT as ordered while monitoring the patient’s neurological status.
B. Position the patient with the affected lung up to reduce ICP.
C. Hold CPT and notify the healthcare provider.
D. Perform only vibration techniques to minimize ICP changes.
C. Hold CPT and notify the healthcare provider.
Rationale: Chest physiotherapy is contraindicated in patients with increased ICP due to the risk of worsening cerebral edema and neurological compromise. The nurse should avoid CPT and inform the provider.
A patient in the ICU with ARDS is found to have pulmonary infiltrates on a chest x-ray and is producing thick secretions. The provider orders postural drainage as part of chest physiotherapy. The nurse should place the patient in which position to facilitate drainage from the posterior lower lobes?
A. High Fowler’s position with the patient leaning forward.
B. Supine with the bed flat and the patient’s head turned to the side.
C. Trendelenburg position with the patient lying prone.
D. Side-lying position with the bed elevated to 45 degrees.
C. Trendelenburg position with the patient lying prone.
Rationale: The Trendelenburg position with the patient prone allows for optimal drainage of the posterior lower lobes by using gravity to move secretions toward larger airways. This position should be avoided in patients with increased ICP or hemodynamic instability.
A nurse is caring for a postoperative patient with a fractured sternum who has developed pulmonary infiltrates. The provider prescribes chest physiotherapy to aid in secretion clearance. What is the nurse’s best response?
A. Proceed with CPT while avoiding percussion over the fractured area.
B. Use high-frequency chest wall oscillation instead of manual CPT.
C. Encourage deep breathing and incentive spirometry instead of CPT.
D. Hold CPT and inform the provider of the contraindication.
D. Hold CPT and inform the provider of the contraindication.
Rationale: Chest physiotherapy is contraindicated in patients with unstable orthopedic injuries, including fractured sternum, as percussion and vibration could worsen the injury. The nurse should hold the therapy and inform the provider.
A nurse is caring for a conscious patient with acute respiratory failure who has thick pulmonary secretions but is unable to expectorate them. The patient has no artificial airway. Which suctioning method is most appropriate?
A. Endotracheal suctioning
B. Oropharyngeal suctioning with a Yankauer catheter
C. Nasopharyngeal suctioning with a soft-tip catheter
D. Deep tracheal suctioning via bronchoscopy
C. Nasopharyngeal suctioning with a soft-tip catheter
Rationale: Nasopharyngeal suctioning is the preferred method for removing secretions in a non-intubated, conscious patient who cannot clear their airway. This technique is effective for reaching secretions at the back of the throat while minimizing discomfort.
A nurse is suctioning a patient with an endotracheal tube (ETT) and notices that the patient’s oxygen saturation drops from 96% to 88% during the procedure. The patient’s heart rate increases, and they become agitated.
What is the nurse’s priority action?
A. Stop suctioning immediately and provide 100% oxygen.
B. Continue suctioning while monitoring the patient’s heart rate.
C. Remove the ET tube and prepare for reintubation.
D. Increase suction pressure to remove secretions more effectively.
A. Stop suctioning immediately and provide 100% oxygen.
Rationale: A drop in oxygen saturation and agitation indicate hypoxia, a possible complication of suctioning. The priority is to stop suctioning and deliver 100% oxygen to prevent further desaturation and respiratory distress.
Which nursing intervention is most important when performing suctioning on a patient with a tracheostomy?
A. Suction continuously while withdrawing the catheter.
B. Apply suction for no longer than 10–15 seconds per pass.
C. Hyperoxygenate the patient after suctioning is complete.
D. Insert the suction catheter until resistance is felt.
B. Apply suction for no longer than 10–15 seconds per pass.
Rationale: Prolonged suctioning (>15 seconds) can cause hypoxia, bradycardia, and airway trauma. Suction should be applied intermittently while withdrawing the catheter to minimize mucosal damage.
A nurse is preparing to suction a conscious, non-intubated patient using a nasopharyngeal catheter. To minimize complications, which action should the nurse take?
A. Encourage the patient to cough before initiating suctioning.
B. Apply suction while advancing the catheter to remove secretions effectively.
C. Use the largest suction catheter available to remove more secretions.
D. Stimulate the gag reflex to encourage secretion clearance.
A. Encourage the patient to cough before initiating suctioning.
Rationale: Encouraging the patient to cough before suctioning helps mobilize secretions naturally, reducing the need for deep suctioning. This minimizes airway trauma and discomfort.
A nurse is caring for a patient receiving high-flow oxygen via an aerosol mask. The patient has thick pulmonary secretions and is receiving nebulized acetylcysteine mixed with a bronchodilator. Which finding requires immediate nursing intervention?
A. Increased coughing after the nebulizer treatment
B. SpO₂ decreasing from 96% to 89% after therapy
C. Mild wheezing heard on auscultation after the treatment
D. Increased expectoration of mucus following the nebulizer use
B. SpO₂ decreasing from 96% to 89% after therapy
Rationale: A sudden drop in oxygen saturation following aerosol therapy suggests bronchospasm or secretion mobilization obstructing airflow. The nurse must intervene immediately by stopping the treatment, assessing for respiratory distress, and possibly administering a bronchodilator or oxygen support.
Which intervention is most appropriate for a patient receiving humidified oxygen therapy via aerosol mask?
A. Increase the oxygen flow rate if the patient experiences mild coughing.
B. Limit nebulizer treatments to once per day to prevent complications.
C. Assess for bronchospasm and oxygen desaturation during treatment.
D. Encourage deep breathing and coughing only after the aerosol therapy is complete.
C. Assess for bronchospasm and oxygen desaturation during treatment.
Rationale: Aerosol therapy can trigger bronchospasm and coughing, potentially leading to a drop in oxygen levels. Continuous assessment ensures prompt intervention if the patient experiences complications.
A nurse is providing education to a new graduate nurse about humidification in secretion management. Which statements should the nurse include? (Select all that apply.)
A. “Humidification helps thin secretions and promotes their removal.”
B. “Mucolytic drugs like acetylcysteine should always be administered alone to prevent adverse effects.”
C. “Bronchospasm is a potential complication of aerosolized humidification therapy.”
D. “Oxygen administered via aerosol mask can assist with secretion clearance.”
E. “Aerosol therapy should be discontinued immediately if the patient starts coughing.”
A. “Humidification helps thin secretions and promotes their removal.”
C. “Bronchospasm is a potential complication of aerosolized humidification therapy.”
D. “Oxygen administered via aerosol mask can assist with secretion clearance.”
Rationale:
* A is correct: Humidification thins secretions and promotes their removal.
* C is correct: Bronchospasm is a possible complication of aerosol therapy.
* D is correct: Oxygen via aerosol mask helps in secretion clearance.
* B is incorrect: Acetylcysteine is often mixed with a bronchodilator to prevent bronchospasm.
* E is incorrect: Mild coughing is expected as secretions loosen; therapy is only stopped if severe distress occurs.
A patient with pneumonia is receiving oxygen therapy via an aerosol mask. The nurse notes that the patient is coughing persistently and reporting increased shortness of breath after the start of nebulized humidification therapy. What is the nurse’s priority action?
A. Continue the therapy and reassure the patient that coughing is expected.
B. Stop the treatment and notify the provider immediately.
C. Assess breath sounds and oxygen saturation while monitoring for bronchospasm.
D. Increase the oxygen flow rate to compensate for increased work of breathing.
C. Assess breath sounds and oxygen saturation while monitoring for bronchospasm.
Rationale: Persistent coughing and shortness of breath could indicate bronchospasm. The nurse should first assess for wheezing, hypoxia, and worsening respiratory distress before deciding on further interventions.
A patient with chronic bronchitis is prescribed humidified oxygen therapy and nebulized acetylcysteine with a bronchodilator. What should the nurse do to ensure patient safety?
A. Administer the acetylcysteine before giving the bronchodilator.
B. Have emergency airway equipment available before starting therapy.
C. Withhold the nebulizer treatment if the patient starts coughing.
D. Limit oxygen administration to prevent oxygen toxicity.
B. Have emergency airway equipment available before starting therapy.
Rationale: Acetylcysteine can trigger bronchospasm. Emergency airway equipment should be available in case of severe respiratory distress.
A nurse is evaluating a patient’s response to nebulized humidification therapy. Which findings indicate that the therapy is effective? (Select all that apply.)
A. Increased ease of breathing
B. Decreased respiratory rate from 24 to 18 breaths/min
C. Thick, sticky secretions that are difficult to expectorate
D. Improved ability to clear secretions by coughing
E. Increased use of accessory muscles for breathing
A. Increased ease of breathing
B. Decreased respiratory rate from 24 to 18 breaths/min
D. Improved ability to clear secretions by coughing
Rationale:
* A is correct: Easier breathing suggests improved secretion clearance.
* B is correct: A decreased respiratory rate indicates less respiratory distress.
* D is correct: Effective coughing means secretions are mobilizing.
* C is incorrect: Secretions should be thinner and easier to expectorate.
* E is incorrect: Increased accessory muscle use suggests worsening distress, not improvement.
A nurse is providing education to a new graduate nurse about humidification in secretion management. Which statements should the nurse include? (Select all that apply.)
A. “Humidification helps thin secretions and promotes their removal.”
B. “Mucolytic drugs like acetylcysteine should always be administered alone to prevent adverse effects.”
C. “Bronchospasm is a potential complication of aerosolized humidification therapy.”
D. “Oxygen administered via aerosol mask can assist with secretion clearance.”
E. “Aerosol therapy should be discontinued immediately if the patient starts coughing.”
A. “Humidification helps thin secretions and promotes their removal.”
C. “Bronchospasm is a potential complication of aerosolized humidification therapy.”
D. “Oxygen administered via aerosol mask can assist with secretion clearance.”
Rationale:
* A is correct: Humidification thins secretions and promotes their removal.
* C is correct: Bronchospasm is a possible complication of aerosol therapy.
* D is correct: Oxygen via aerosol mask helps in secretion clearance.
* B is incorrect: Acetylcysteine is often mixed with a bronchodilator to prevent bronchospasm.
* E is incorrect: Mild coughing is expected as secretions loosen; therapy is only stopped if severe distress occurs.
A patient with acute respiratory failure (ARF) has thick pulmonary secretions. The provider prescribes IV fluids at 100 mL/hr. The nurse notes new-onset crackles in the lung bases, mild dyspnea, and an increase in central venous pressure (CVP) from 6 mm Hg to 12 mm Hg. What is the nurse’s priority action?
A. Increase the IV fluid rate to 125 mL/hr to further thin secretions.
B. Stop the IV fluids immediately and notify the provider.
C. Reduce the IV fluid rate and monitor respiratory status closely.
D. Encourage the patient to drink additional oral fluids to replace IV hydration.
C. Reduce the IV fluid rate and monitor respiratory status closely.
Rationale: New-onset crackles, dyspnea, and elevated CVP suggest early fluid overload. The nurse should slow the IV fluid rate while monitoring respiratory status to prevent pulmonary edema.
A nurse is providing discharge teaching to a patient with chronic bronchitis about maintaining adequate hydration to promote secretion clearance. Which statement by the patient indicates a need for further education?
A. “I should aim to drink at least 2 to 3 liters of fluids daily unless my doctor says otherwise.”
B. “Drinking more fluids will help thin my mucus and make it easier to cough up.”
C. “If I feel short of breath or notice swelling, I should drink extra fluids to keep my lungs clear.”
D. “If I can’t drink enough fluids, I may need IV hydration to prevent thick mucus buildup.”
C. “If I feel short of breath or notice swelling, I should drink extra fluids to keep my lungs clear.”
Rationale: Shortness of breath and swelling may indicate fluid overload, not dehydration. Increasing fluid intake in this situation could worsen pulmonary edema.
A patient with pneumonia and acute kidney injury (AKI) has thick, difficult-to-expectorate secretions. The nurse notes a urine output of 20 mL/hr for the past 6 hours, increasing respiratory distress, and bilateral crackles. What is the most appropriate intervention?
A. Administer a diuretic to remove excess fluid.
B. Increase IV fluid administration to thin secretions.
C. Encourage the patient to drink 3 liters of fluid daily.
D. Notify the provider and anticipate a fluid restriction.
D. Notify the provider and anticipate a fluid restriction.
Rationale: Oliguria (low urine output), worsening respiratory distress, and crackles suggest fluid retention due to AKI. Increasing fluids could worsen pulmonary edema, so the nurse should anticipate fluid restriction and notify the provider.
A nurse is assessing a patient receiving IV hydration for thick respiratory secretions. Which findings indicate possible fluid overload? (Select all that apply.)
A. New-onset bilateral crackles
B. Jugular vein distention
C. Urine output of 50 mL/hr
D. Sudden weight gain of 2 kg (4.4 lbs) in 24 hours
E. Increased work of breathing
A. New-onset bilateral crackles
B. Jugular vein distention
D. Sudden weight gain of 2 kg (4.4 lbs) in 24 hours
E. Increased work of breathing
Rationale:
- A is correct: Crackles suggest pulmonary congestion due to excess fluid.
- B is correct: Jugular vein distention indicates increased central venous pressure.
- D is correct: Rapid weight gain signals fluid retention.
- E is correct: Increased work of breathing suggests worsening respiratory distress.
- C is incorrect: A urine output of 50 mL/hr is normal and does not indicate fluid overload.
A patient with acute respiratory failure (ARF) secondary to a COPD exacerbation is placed on bilevel positive airway pressure (BiPAP). The nurse observes increased agitation, tachypnea, and a decreasing oxygen saturation from 92% to 85%. What is the nurse’s priority action?
A. Increase the FiO₂ setting on the BiPAP machine.
B. Assess for proper mask fit and ensure the patient is tolerating the therapy.
C. Switch the patient from BiPAP to CPAP.
D. Discontinue BiPAP and prepare for immediate intubation.
B. Assess for proper mask fit and ensure the patient is tolerating the therapy.
Rationale: Agitation and hypoxemia may indicate mask leaks or intolerance to BiPAP. The first step is to assess mask fit and ensure adequate ventilation before considering escalation to intubation.
A patient with end-stage COPD who refuses intubation is started on BiPAP. Which assessment finding would indicate the therapy is effective?
A. Increased use of accessory muscles
B. Decreased work of breathing and improved mental status
C. Increased respiratory rate from 18 to 26 breaths per minute
D. Development of facial skin breakdown from the mask
B. Decreased work of breathing and improved mental status
Rationale: BiPAP should reduce respiratory muscle fatigue, improve oxygenation, and decrease work of breathing. Improved mental status indicates better oxygen delivery to the brain.
A patient with ARF due to pneumonia is placed on continuous positive airway pressure (CPAP). The nurse notes the patient is drowsy, has a respiratory rate of 10 breaths per minute, and PaCO₂ is 60 mmHg. What intervention should the nurse anticipate?
A. Continue CPAP therapy and monitor respiratory status.
B. Switch the patient from CPAP to BiPAP.
C. Increase the CPAP pressure setting.
D. Prepare for endotracheal intubation.
D. Prepare for endotracheal intubation.
Rationale: Drowsiness, decreased respiratory rate, and increasing PaCO₂ suggest CO₂ retention and respiratory failure. CPAP does not provide ventilation support, so intubation is necessary to correct hypercapnia.
Which patients are not appropriate candidates for noninvasive positive pressure ventilation (NIPPV)? (Select all that apply.)
A. A patient with stable COPD exacerbation and mild hypercapnia
B. A patient with severe facial trauma
C. A patient with ARF and copious respiratory secretions
D. A patient with congestive heart failure and pulmonary edema
E. A patient with altered mental status and inability to protect the airway
B. A patient with severe facial trauma
C. A patient with ARF and copious respiratory secretions
E. A patient with altered mental status and inability to protect the airway
Rationale:
* B is correct: Facial trauma prevents an adequate mask seal for effective ventilation.
- C is correct: Excessive secretions increase aspiration risk and compromise airway clearance.
- E is correct: An altered mental status impairs the ability to maintain a patent airway.
- A and D are incorrect because BiPAP/CPAP can effectively manage COPD exacerbations and pulmonary edema.
A nurse is explaining the difference between CPAP and BiPAP to a new graduate. Which statement is accurate?
A. “CPAP provides two levels of pressure, while BiPAP delivers a constant pressure.”
B. “BiPAP is preferred for ARF because it provides different pressures for inhalation and exhalation.”
C. “CPAP assists with ventilation, while BiPAP only provides oxygenation support.”
D. “Both CPAP and BiPAP require the patient to be intubated.”
B. “BiPAP is preferred for ARF because it provides different pressures for inhalation and exhalation.”
Rationale: BiPAP delivers higher pressure during inhalation and lower pressure during exhalation, reducing work of breathing. CPAP provides a constant pressure throughout the respiratory cycle.
A patient on BiPAP reports abdominal bloating, belching, and epigastric discomfort. What is the most likely cause?
A. Air is being forced into the esophagus and stomach.
B. The BiPAP pressure is too low.
C. The mask is too loose, causing air leaks.
D. The patient is experiencing an allergic reaction to the mask.
Air is being forced into the esophagus and stomach.
Rationale: Excessive BiPAP pressure can lead to gastric insufflation, causing bloating and discomfort. The nurse should assess the pressure settings and consider adjusting them.
A patient is started on BiPAP for ARF. The nurse should assess the patient for which potential complication?
A. Hypoventilation and CO₂ retention
B. Barotrauma and pneumothorax
C. Hypotension from positive pressure
D. All of the above
D. All of the above
Rationale: BiPAP can cause hypoventilation if settings are inadequate, barotrauma from excessive pressure, and hypotension due to reduced venous return.
A patient with CHF and pulmonary edema is placed on CPAP. Which finding indicates the therapy is working?
A. Worsening dyspnea and increased blood pressure
B. Increased work of breathing and use of accessory muscles
C. Decreased respiratory rate and improved SpO₂
D. Increasing crackles and frothy sputum production
C. Decreased respiratory rate and improved SpO₂
Rationale: CPAP should improve oxygenation and reduce respiratory distress by decreasing fluid accumulation in the lungs.
Which statement by a patient on BiPAP requires immediate intervention?
A. “My skin feels sore where the mask is pressing.”
B. “I feel bloated after using the machine for an hour.”
C. “I feel really sleepy and can’t stay awake.”
D. “I have a mild headache after waking up.”
C. “I feel really sleepy and can’t stay awake.”
Rationale: Excessive drowsiness may indicate CO₂ retention and worsening respiratory failure. The nurse should assess PaCO₂ levels and ventilatory support.
Which interventions can help prevent complications of BiPAP therapy? (Select all that apply.)
A. Apply a skin barrier to prevent facial pressure ulcers.
B. Monitor for gastric insufflation and abdominal bloating.
C. Increase inspiratory pressure if the patient complains of discomfort.
D. Assess for signs of CO₂ retention and altered mental status.
E. Ensure the patient remains NPO to prevent aspiration.
A. Apply a skin barrier to prevent facial pressure ulcers.
B. Monitor for gastric insufflation and abdominal bloating.
D. Assess for signs of CO₂ retention and altered mental status.
Rationale:
* A is correct: Skin breakdown is a common complication.
- B is correct: Gastric insufflation can cause discomfort and nausea.
- D is correct: CO₂ retention may occur if settings are inadequate.
- C is incorrect: Increasing inspiratory pressure without assessment may worsen discomfort.
- E is incorrect: Patients do not need to be NPO unless they have aspiration risk
A patient with acute respiratory failure (ARF) is receiving drug therapy to treat bronchospasm and inflammation. Which of the following medications would the nurse anticipate being ordered for this patient to reduce airway inflammation and bronchospasm?
A. Corticosteroids
B. Diuretics
C. Beta-blockers
D. Analgesics
A. Corticosteroids
Rationale: Corticosteroids are used to reduce airway inflammation and bronchospasm in patients with respiratory conditions like ARF. They help improve airflow by decreasing inflammation in the airways.
A patient with ARF has a history of chronic obstructive pulmonary disease (COPD) and is now showing signs of infection. The physician orders antibiotics to treat the infection and bronchodilators to reduce bronchospasm. What is the nurse’s priority when administering these medications?
A. Administer antibiotics first, followed by bronchodilators.
B. Administer bronchodilators first, followed by antibiotics.
C. Administer both medications simultaneously.
D. Withhold both medications until the patient is stable.
B. Administer bronchodilators first, followed by antibiotics.
Rationale: Bronchodilators should be administered before antibiotics because they help open the airways, allowing the antibiotics to reach the lungs more effectively. Administering bronchodilators first reduces airway resistance and optimizes the patient’s ability to inhale the medication.
A patient with ARF is experiencing anxiety and restlessness. Which of the following drugs would the nurse anticipate administering to address the patient’s symptoms?
A. Antibiotics
B. Diuretics
C. Benzodiazepines
D. Corticosteroids
C. Benzodiazepines
Rationale: Benzodiazepines are used to reduce anxiety and restlessness in patients with ARF. They help to calm the patient and improve comfort while the primary respiratory issues are being addressed.
A patient with acute bronchospasm is being treated with a short-acting bronchodilator. The nurse knows that the patient may experience which of the following side effects?
A. Hypotension and bradycardia
B. Tachypnea and hypoglycemia
C. Bradycardia and hyperkalemia
D. Tachycardia and hypertension
D. Tachycardia and hypertension
Rationale: Short-acting bronchodilators (e.g., albuterol) can cause tachycardia and hypertension as side effects. These are due to the sympathetic nervous system stimulation caused by the medication.
A patient with acute bronchospasm is receiving albuterol via a metered-dose inhaler every 30 minutes as prescribed. The nurse observes that the patient’s heart rate increases and blood pressure rises. What is the nurse’s priority action?
A. Monitor vital signs and document the findings.
B. Administer a dose of inhaled corticosteroids.
C. Discontinue the albuterol and notify the physician.
D. Continue the treatment as prescribed, as these are expected side effects.
C. Discontinue the albuterol and notify the physician.
Rationale: The nurse should discontinue the albuterol if significant side effects like tachycardia and hypertension occur, and notify the physician immediately. These side effects may indicate excessive stimulation of the sympathetic nervous system, which could lead to complications such as dysrhythmias or cardiac ischemia.
A patient with acute bronchospasm is being treated with inhaled corticosteroids. The nurse understands that the effects of this treatment may take:
A. Immediate relief of symptoms within minutes
B. 4 to 5 days for optimum therapeutic effects
C. Several hours for full relief
D. Several days to become effective, but no more than 24 hours
B. 4 to 5 days for optimum therapeutic effects
Rationale: Inhaled corticosteroids typically take 4 to 5 days to achieve optimum therapeutic effects and may not provide immediate relief of symptoms or quick relief of dyspnea or increased work of breathing (WOB).
A nurse is administering IV methylprednisolone to a patient with acute bronchospasm. The patient asks how long it will take for the medication to relieve symptoms. What is the nurse’s most appropriate response?
A. “This medication will provide immediate relief of symptoms.”
B. “This medication will relieve symptoms within 30 minutes.”
C. B. “It will take a few hours for this medication to work.”
D. “It may take several days for the full effect to be felt.”
C. B. “It will take a few hours for this medication to work.”
Rationale: IV methylprednisolone may take several hours to show therapeutic effects, especially in terms of reducing inflammation and bronchospasm. It is not an immediate-acting medication for acute bronchospasm.
A patient has been using albuterol every 15 to 30 minutes due to worsening bronchospasm. The nurse notes an increase in the patient’s heart rate and blood pressure. Which action should the nurse take?
A. Continue the medication as prescribed, as this is expected.
B. Notify the physician immediately and request an alternative bronchodilator.
C. Administer IV corticosteroids immediately.
D. Assess the patient’s respiratory status and hold further doses of albuterol if necessary.
D. Assess the patient’s respiratory status and hold further doses of albuterol if necessary.
Rationale: Tachycardia and hypertension are potential side effects of albuterol. The nurse should assess the patient’s respiratory status and vital signs and withhold further doses if needed, notifying the physician about the side effects and patient condition.
The nurse is administering IV methylprednisolone for a patient with acute bronchospasm. The nurse should be aware that this medication may take several hours to relieve symptoms. What is the primary goal of combining corticosteroids with bronchodilators?
A. To reduce airway inflammation and relieve bronchospasm
B. To treat infection and reduce airway resistance
C. To promote oxygenation and reduce pulmonary edema
D. To increase blood pressure and improve cardiac output
A. To reduce airway inflammation and relieve bronchospasm
Rationale: Corticosteroids, such as methylprednisolone, are combined with bronchodilators to reduce airway inflammation and relieve bronchospasm, improving airflow and oxygenation. They work together to address both inflammation and airway constriction.
A patient with chronic asthma is admitted for acute bronchospasm and is receiving albuterol via nebulizer. The nurse monitors the patient’s ECG and vital signs, noting increased tachycardia. What is the most appropriate nursing intervention?
A. Administer IV fluids to correct the tachycardia.
B. Discontinue the albuterol and notify the healthcare provider.
C. Increase the dose of albuterol to manage bronchospasm.
D. Continue monitoring the patient as these are expected side effects of albuterol.
B. Discontinue the albuterol and notify the healthcare provider.
Rationale: Tachycardia is a potential side effect of albuterol and can indicate excessive sympathetic nervous system stimulation. Discontinuing the medication and notifying the healthcare provider is the appropriate action, as the patient may need a different treatment plan to manage bronchospasm.
A patient with pulmonary congestion secondary to heart failure (HF) is receiving IV furosemide to reduce fluid overload. The nurse should monitor for which of the following potential side effects of this medication?
A. Hypotension and tachycardia
B. Bradycardia and hypokalemia
C. Hypokalemia and hypotension
D. Hypertension and bradycardia
C. Hypokalemia and hypotension
Rationale: Furosemide (a diuretic) can cause hypokalemia (low potassium) and hypotension (low blood pressure). These are common side effects of diuretics, which promote fluid loss. The nurse should closely monitor the patient’s electrolyte levels and blood pressure.
A patient with heart failure (HF) is receiving morphine to reduce pulmonary congestion. The nurse should closely monitor the patient for which of the following?
A. Decreased respiratory rate and hypotension
B. Increased heart rate and elevated blood pressure
C. Increased respiratory rate and hypertension
D. Elevated temperature and tachypnea
A. Decreased respiratory rate and hypotension
Rationale: Morphine can cause respiratory depression (decreased respiratory rate) and hypotension (low blood pressure). It is used in pulmonary congestion for its ability to reduce anxiety, decrease venous return, and improve oxygenation, but the nurse must monitor for these side effects.
A nurse is administering nitroglycerin to a patient with pulmonary congestion caused by heart failure. Which of the following should the nurse closely monitor due to the potential side effects of this medication?
A. Blood pressure and heart rate
B. Serum glucose and sodium levels
C. Oxygen saturation and body temperature
D. Respiratory rate and temperature
A. Blood pressure and heart rate
Rationale: Nitroglycerin works by reducing pulmonary congestion and preload, but it can cause significant decreases in blood pressure and changes in heart rate. The nurse should closely monitor the patient’s vital signs, especially for hypotension or bradycardia.
A patient with heart failure (HF) is experiencing pulmonary congestion and is prescribed IV diuretics (e.g., furosemide) and morphine. The nurse recognizes that caution should be used when administering these medications due to which of the following concerns?
A. Risk for increased heart rate and decreased BP
B. Risk for fluid overload and hyperkalemia
C. Risk for dysrhythmias and hypotension
D. Risk for respiratory depression and fluid retention
C. Risk for dysrhythmias and hypotension
Rationale: Both IV diuretics (e.g., furosemide) and morphine can lead to hypotension and dysrhythmias. Diuretics can cause fluid and electrolyte imbalances, and morphine can reduce blood pressure and cause respiratory depression. Monitoring the patient’s vital signs and ECG is essential for preventing complications.
A patient with acute respiratory failure (ARF) has developed a lung infection resulting in excessive mucus production and fever. The nurse understands that the infection may cause worsening ARF because:
A. Inflammation and fluid-filled alveoli prevent gas exchange
B. Mucus production increases tidal volume
C. Fever reduces the body’s metabolic rate
D. The increased O2 consumption reduces respiratory rate
A. Inflammation and fluid-filled alveoli prevent gas exchange
Rationale: Pulmonary infections (e.g., pneumonia) can cause inflammation and fluid-filled alveoli, which prevents effective gas exchange. This results in a worsening of ARF as the alveoli cannot properly exchange oxygen and carbon dioxide.
A patient with acute bronchitis has been diagnosed with a lung infection causing excessive mucus production and worsening acute respiratory failure (ARF). Which of the following interventions is most appropriate to treat the infection?
A. Administering IV antibiotics and obtaining sputum cultures
B. Starting high-flow oxygen therapy without antibiotics
C. Administering oral steroids for inflammation control
D. Discontinuing antibiotics once symptoms improve
A. Administering IV antibiotics and obtaining sputum cultures
Rationale: The most effective treatment for lung infections involves IV antibiotics to treat the infection and obtaining sputum cultures to identify the causative organism and guide antimicrobial therapy. This will help manage infection and prevent further complications of ARF.
A patient with acute respiratory failure (ARF) is being evaluated for a suspected lung infection. The nurse anticipates that a chest x-ray will be used to:
A. Identify the organism causing the infection
B. Assess the location and extent of lung involvement
C. Measure the patient’s oxygen saturation levels
D. Determine the size of the alveolar collapse
B. Assess the location and extent of lung involvement
Rationale: A chest x-ray is an essential diagnostic tool used to assess the location and extent of the infection, including fluid-filled or collapsed alveoli. It provides visual evidence of the infection’s severity and helps guide further treatment decisions.
A patient with acute respiratory failure (ARF) has a lung infection that was confirmed by sputum cultures. The nurse should be prepared for which of the following outcomes after initiating IV antibiotics?
A. Arterial blood gases (ABG) will improve, and oxygen requirements will increase
B. Tachypnea should resolve, and respiratory rate should decrease
C. Blood pressure will stabilize, and heart rate will decrease
D. Sputum production should decrease, and fever should subside
D. Sputum production should decrease, and fever should subside
Rationale: After starting IV antibiotics, the patient should show improvement in infection symptoms. Sputum production should decrease, and fever should subside as the infection is controlled. Monitoring these changes is essential in determining the effectiveness of the treatment.
Which diagnostic test is critical in identifying the organisms causing a lung infection in a patient with acute respiratory failure (ARF)?
A. Arterial blood gases (ABG)
B. Sputum culture
C. Electrocardiogram (ECG)
D. Pulmonary function tests (PFTs)
B. Sputum culture
Rationale: Sputum cultures are essential in identifying the specific organisms causing the lung infection and determining their sensitivity to antimicrobial drugs. This helps guide the most appropriate treatment with antibiotics.
A nurse is caring for a patient with acute respiratory failure (ARF) who is experiencing anxiety, restlessness, and dyspnea. The nurse understands that these symptoms may contribute to which of the following?
A. Increased oxygen consumption and carbon dioxide production
B. Decreased oxygen consumption and carbon dioxide production
C. Improved ventilation and oxygenation
D. Reduced work of breathing
A. Increased oxygen consumption and carbon dioxide production
Rationale: Anxiety, pain, and restlessness can increase oxygen consumption and carbon dioxide production due to an elevated metabolic rate, which increases the work of breathing (WOB). This can worsen hypoxemia and dyspnea in patients with ARF.
A patient who is not intubated is experiencing anxiety and tachypnea due to dyspnea. What is the nurse’s priority in addressing the patient’s symptoms?
A. Administer IV lorazepam to reduce anxiety
B. Increase the patient’s oxygen flow rate
C. Assess for treatable causes such as hypoxemia or pain
D. Use opioids to relieve pain and dyspnea
C. Assess for treatable causes such as hypoxemia or pain
Rationale: The priority is to assess for treatable causes such as hypoxemia, pain, or ventilator dyssynchrony. Restlessness and mental status changes are often the first signs of these conditions, so addressing the underlying cause is essential before administering sedatives or analgesics.
Which of the following interventions is most effective in reducing anxiety and restlessness in a non-intubated patient with acute respiratory failure (ARF)?
A. Administering high doses of morphine
B. Increasing oxygen flow rate to the maximum level
C. Providing emotional support and reassurance
D. Administering lorazepam and increasing sedation
C. Providing emotional support and reassurance
Rationale: Providing emotional support and reassurance to the patient and caregiver is critical in reducing anxiety and restlessness. This approach can help alleviate the stress caused by the patient’s condition, improving overall comfort.
A patient receiving mechanical ventilation is exhibiting restlessness and ventilator dyssynchrony. The nurse suspects that this may be caused by hypoxemia. What is the nurse’s priority action?
A. Increase the sedative dosage
B. Adjust the ventilator settings to improve synchronization
C. Administer IV morphine for pain relief
D. Administer IV lorazepam to manage anxiety
B. Adjust the ventilator settings to improve synchronization
Rationale: If ventilator dyssynchrony is suspected, it is important to first adjust the ventilator settings to improve synchronization. This helps reduce restlessness and improve overall ventilatory support. Managing hypoxemia and adjusting the ventilator settings are more effective than solely increasing sedatives.
A patient with acute respiratory failure (ARF) is being treated with IV lorazepam and morphine for anxiety and pain. Which of the following should the nurse monitor for as potential complications of these medications?
A. Hypoxemia and elevated blood pressure
B. Tachycardia and hypercapnia
C. Increased work of breathing and tachypnea
D. Respiratory depression and hypotension
D. Respiratory depression and hypotension
Rationale: Benzodiazepines and opioids like lorazepam and morphine can cause respiratory depression and hypotension as side effects. Monitoring the patient for these complications is essential to ensure safe medication use and prevent further respiratory compromise.
A patient with acute respiratory failure (ARF) is being treated with IV lorazepam for anxiety and restlessness. The nurse observes that the patient’s mental status has worsened. What is the nurse’s most appropriate action?
A. Increase the lorazepam dosage
B. Discontinue lorazepam and replace it with opioid analgesics
C. Administer a higher dose of oxygen to improve mental status
D. Assess for treatable causes of the restlessness, such as hypoxemia or pain
D. Assess for treatable causes of the restlessness, such as hypoxemia or pain
Rationale: Restlessness and mental status changes are often early signs of hypoxemia or other treatable conditions. The nurse should assess and address the underlying causes rather than immediately increasing the dose of lorazepam, which could worsen the patient’s condition.
The nurse is caring for a patient with acute respiratory failure (ARF) who is showing signs of ventilator dyssynchrony and is anxious about being on the ventilator. Which of the following interventions would be most appropriate to reduce the risk of unplanned extubation?
A. Provide reassurance and maintain frequent communication with the patient
B. Increase the sedative dosage to keep the patient calm
C. Reposition the patient frequently to reduce anxiety
D. Administer narcotics to control pain
A. Provide reassurance and maintain frequent communication with the patient
Rationale: Reassurance and maintaining frequent communication with the patient can help reduce anxiety and prevent unplanned extubation. Providing emotional support and explaining the ventilator settings and goals can increase patient cooperation and comfort.
A nurse is caring for a patient who is receiving both IV lorazepam and IV morphine for anxiety and pain related to acute respiratory failure (ARF). The nurse must prioritize which of the following assessments?
A. Oxygen saturation levels and respiratory rate
B. Bowel sounds and urinary output
C. Heart rate and blood pressure
D. Neurological status and ECG readings
A. Oxygen saturation levels and respiratory rate
Rationale: Lorazepam and morphine can cause respiratory depression, so it is crucial to closely monitor oxygen saturation and respiratory rate to detect any potential respiratory compromise and ensure patient safety.
A patient with acute respiratory failure (ARF) is receiving IV lorazepam for anxiety. The nurse knows that the initial dose of this medication should be:
A. As high as possible to ensure rapid relief of symptoms
B. The lowest possible dose to reduce the risk of sedation
C. Administered based on the patient’s weight and height
D. Given immediately after starting mechanical ventilation
B. The lowest possible dose to reduce the risk of sedation
Rationale: It is important to administer lorazepam at the lowest possible dose to reduce the risk of over-sedation and respiratory depression. The goal is to manage anxiety without compromising the patient’s respiratory status.
A patient with critical illness is experiencing a hypermetabolic state. The nurse understands that the primary concern in this patient’s nutrition therapy is:
A. Maintaining a high-fat, low-protein diet
B. Preventing protein and energy depletion
C. Decreasing caloric intake to avoid weight gain
D. Increasing fluid intake to prevent dehydration
B. Preventing protein and energy depletion
Rationale: In a hypermetabolic state, such as critical illness, it is crucial to maintain protein and energy stores to prevent depletion, which could lead to loss of muscle mass (including respiratory muscles) and delay recovery.
A patient with acute respiratory failure is admitted to the ICU. The dietitian suggests starting enteral nutrition (EN) within 24 to 48 hours. What is the nurse’s primary rationale for this recommendation?
A. EN helps avoid fluid retention and electrolyte imbalances
B. EN supports protein and energy stores to prevent muscle mass loss
C. EN reduces the risk of aspiration pneumonia in critically ill patients
D. EN decreases the need for mechanical ventilation in respiratory failure
B. EN supports protein and energy stores to prevent muscle mass loss
Rationale: Enteral nutrition (EN) is recommended within 24 to 48 hours of admission to maintain protein and energy stores to prevent muscle mass loss, which is especially important in critical illness, as muscle loss can delay recovery.
The nurse is caring for a critically ill patient who is in a hypermetabolic state. The dietitian has recommended enteral nutrition (EN) for the patient. The nurse understands that the primary goal of EN in this patient is to:
A. Minimize the need for pharmacologic interventions
B. Increase the patient’s energy stores and support muscle mass
C. Prevent the development of GI ulcers
D. Promote gastrointestinal motility and prevent constipation
B. Increase the patient’s energy stores and support muscle mass
Rationale: The primary goal of enteral nutrition (EN) is to provide adequate energy and protein to support muscle mass and energy stores in the face of a hypermetabolic state, which is critical in preventing further muscle wasting and delayed recovery.
The nurse is preparing to implement enteral nutrition (EN) for a critically ill patient. The dietitian has provided the feeding plan based on the patient’s nutritional needs. What is the nurse’s role in this process?
A. Determine the patient’s optimal calorie and fluid requirements
B. Select the appropriate feeding tube and initiate feeding immediately
C. Administer parenteral nutrition instead of enteral nutrition
D. Assess the patient’s response to nutrition therapy and adjust as necessary
D. Assess the patient’s response to nutrition therapy and adjust as necessary
Rationale: The nurse’s role in enteral nutrition (EN) therapy includes assessing the patient’s response to the therapy and making necessary adjustments. The dietitian typically determines the optimal calorie and fluid requirements and feeding method, but ongoing monitoring and adjustments by the nurse are essential to ensure adequate nutritional support.
The nurse is evaluating a patient with acute respiratory failure (ARF). Which of the following outcomes would indicate successful management of the patient’s condition?
A. The patient requires assistance to maintain a patent airway
B. The patient exhibits signs of severe hypoxia despite interventions
C. The patient’s oxygenation is stable, with a PaO2 within the normal range
D. The patient has an increased need for mechanical ventilation
C. The patient’s oxygenation is stable, with a PaO2 within the normal range
Rationale: A successful outcome in the management of ARF includes adequate oxygenation, demonstrated by a normal PaO2. Maintaining oxygenation is one of the key expected outcomes in ARF management.
A nurse is evaluating a patient recovering from acute respiratory failure (ARF). Which of the following outcomes would best indicate that the patient’s respiratory function has returned to baseline?
A. The patient no longer requires supplemental oxygen
B. The patient remains on mechanical ventilation
C. The patient reports increased shortness of breath on exertion
D. The patient’s vital signs remain unstable with fluctuating blood pressure
A. The patient no longer requires supplemental oxygen
Rationale: Returning to baseline respiratory function means the patient has sufficient respiratory function to maintain oxygenation without supplemental oxygen. This reflects improved respiratory health and stability.
When evaluating a patient with ARF, the nurse observes that the patient is hemodynamically unstable and requires significant oxygen support. Which expected outcome indicates that the patient’s condition is improving?
A. The patient’s vital signs remain unstable, with fluctuating blood pressure and tachycardia
B. The patient exhibits increased work of breathing despite receiving oxygen therapy
C. The patient’s oxygen saturation remains below 90% despite interventions
D. The patient requires less oxygen and demonstrates stable hemodynamics
D. The patient requires less oxygen and demonstrates stable hemodynamics
Rationale: An improvement in ARF is indicated when the patient requires less oxygen and demonstrates stable hemodynamics, meaning their cardiovascular and respiratory functions are stabilizing and returning to baseline levels.
An older adult with ARF has poor nutrition status and limited physiologic reserve in the cardiopulmonary system. The nurse anticipates that which of the following factors will most likely contribute to the progression of ARF?
A. The ability of the respiratory system to compensate for gas exchange changes
B. The decreased physiologic reserve and poor nutritional status of the patient
C. The presence of adequate ventilatory capacity due to aging
D. The increase in respiratory muscle strength despite aging changes
B. The decreased physiologic reserve and poor nutritional status of the patient
Rationale: Decreased physiologic reserve and poor nutritional status make older adults more susceptible to worsening ARF due to the inability to compensate for respiratory and metabolic stresses.
In an older adult with ARF, which of the following age-related respiratory changes contributes to the development of respiratory insufficiency?
A. Increased ability to respond to low oxygen levels
B. Increased elastic recoil within the airways
C. Decreased response to changes in PaO2 and PaCO2 levels
D. Increased efficiency of the alveolar-capillary membrane
C. Decreased response to changes in PaO2 and PaCO2 levels
Rationale: Older adults have a decreased response to changes in PaO2 and PaCO2 levels, which contributes to respiratory insufficiency and increases the risk of ARF.
When educating an older patient with ARF about the role of tobacco use in respiratory health, which of the following statements by the nurse is most accurate?
A. Tobacco use has no significant impact on the aging process of the respiratory system
B. Tobacco use accelerates age-related changes in the respiratory system
C. Tobacco use helps improve lung elasticity and respiratory muscle strength
D. Tobacco use decreases the risk of respiratory insufficiency in older adults
B. Tobacco use accelerates age-related changes in the respiratory system
Rationale: Tobacco use accelerates age-related respiratory changes, such as decreased lung elasticity and muscle strength, which increases the risk of respiratory failure.
An older adult patient with ARF has difficulty maintaining adequate oxygenation. The nurse understands that which of the following physiological changes due to aging increases this patient’s risk for respiratory failure?
A. Increased alveolar surface area for more effective gas exchange
B. Increased muscle strength contributing to better respiratory function
C. Decreased chest wall compliance and respiratory muscle strength
D. Improved oxygen exchange due to larger air spaces in the lungs
C. Decreased chest wall compliance and respiratory muscle strength
Rationale: Aging causes decreased chest wall compliance and reduced respiratory muscle strength, which reduces ventilatory efficiency and contributes to the increased risk of ARF.
The nurse is assessing an older adult with ARF. The nurse recognizes that aging can affect the respiratory system by causing which of the following?
A. Increased PaO2 levels, enhancing oxygenation
B. Decreased alveolar dilation, reducing the risk of ARF
C. Increased ventilatory capacity, improving lung function
D. Decreased ventilatory capacity, leading to an increased risk of ARF
D. Decreased ventilatory capacity, leading to an increased risk of ARF
Rationale: Aging results in decreased ventilatory capacity, which increases the risk of ARF due to changes such as alveolar dilation, decreased lung elasticity, and diminished respiratory muscle strength.
An older patient has a history of tobacco use and is now experiencing signs of respiratory insufficiency. What factor associated with aging contributes to this patient’s delayed response to respiratory changes?
A. Increased lung compliance
B. Decreased alveolar surface area for gas exchange
C. Increased PaCO2 levels and delayed stimulation of the respiratory system
D. Increased muscle strength improving lung function
C. Increased PaCO2 levels and delayed stimulation of the respiratory system
Rationale: Aging causes the PaCO2 levels to rise higher before the respiratory system is stimulated to change the rate and depth of breathing, resulting in a delayed response to respiratory insufficiency.
An older adult is admitted with acute respiratory failure (ARF). Which of the following factors contributes to the increased risk of ARF in older adults?
A. Increased alveolar surface area for gas exchange
B. Increased chest wall compliance
C. Decreased respiratory muscle strength and lung elasticity
D. Increased PaO2 levels
C. Decreased respiratory muscle strength and lung elasticity
Rationale: Aging leads to decreased respiratory muscle strength, reduced lung elasticity, and decreased chest wall compliance, all of which contribute to the increased risk of ARF in older adults.
Which signs and symptoms lead the nurse to suspect hypoxemic rather than hypercapnic respiratory failure? (select all that apply)
a. Cyanosis
b. Tachypnea
c. Morning headache
d. Paradoxical breathing
e. Use of pursed-lip breathing
a. Cyanosis
b. Tachypnea
d. Paradoxical breathing
An important consideration in selecting an O2 delivery device for the patient with acute hypoxemic respiratory failure is to
a. always start with noninvasive positive pressure ventilation.
b. apply a low-flow device, such as a nasal cannula or face mask.
c. be able to correct the PaO2 to a normal level as quickly as possible.
d. base the selection on the patient’s condition and amount of FIO2 needed.
d. base the selection on the patient’s condition and amount of FIO2 needed.
Which diagnostic test would provide the nurse with the most specific information to evaluate the effectiveness of interventions for a patient with ventilatory failure?
a. Chest x-ray
b. O 2 saturation
c. Arterial blood gases
d. Central venous pressure
c. Arterial blood gases
Rationale: Arterial blood gas (ABG) analysis is the most specific information because ventilatory failure causes problems with CO2 retention, and ABGs give information about the PaCO 2 and pH. Chest x-ray, oxygen saturation, and central venous pressure monitoring may also be done to help in assessing oxygenation or determining the cause of the patient‘s ventilatory failure.
A patient who was admitted with a pulmonary embolism has a change in oxygen saturation (SpO 2 ) from 94% to 88%. Which action would the nurse take?
a. Suction the patient‘s oropharynx.
b. Increase the prescribed O2 flowrate.
c. Teach the patient to cough and deep breathe.
d. Help the patient to sit in an upright position.
b. Increase the prescribed O 2 flowrate.
Rationale: Increasing O2 flowrate will usually improve O2 saturation in patients with ventilation-perfusion mismatch, as occurs with pulmonary embolism. Because the problem is with perfusion, actions that improve ventilation, such as deep breathing and coughing, sitting upright, and suctioning, are not likely to improve oxygenation.
A patient with respiratory failure is increasingly lethargic, with a respiratory rate of 6 breaths/min and an oxygen saturation (SpO 2 ) of 78%. Which intervention would the nurse anticipate?
a. Administration of 100% O 2 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)
b. Endotracheal intubation and positive pressure ventilation
Rationale: The patient‘s lethargy, low respiratory rate, and SpO2 indicate the need for mechanical ventilation with ventilator-controlled respiratory rate. Giving high-flow O2 will not be helpful because the patient‘s respiratory rate is so low. Insertion of a mini-tracheostomy will promote removal of secretions, but it will not improve the patient‘s respiratory rate or oxygenation. CPAP requires that the patient initiate an adequate respiratory rate to allow adequate gas exchange.
The oxygen saturation (SpO 2 ) for a patient with left lower lobe pneumonia is 90%. The patient has wheezes and a weak cough effort. Which action would the nurse 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 4-hour rest period for the patient.
b. Assist the patient with staged coughing.
Rationale: The patient‘s assessment indicates that assisted coughing is needed to help remove secretions, which will improve oxygenation. A 4-hour rest period at this time may allow the O2 saturation to drop further. Humidification will not be helpful unless the secretions can be mobilized. Positioning on the left side may cause a further decrease in oxygen saturation because perfusion will be directed more toward the more poorly ventilated lung.
A nurse is caring for a patient with right lower lobe pneumonia who is obese. Which position will provide the best gas exchange?
a. On the left side
b. On the right side
c. In the tripod position
d. In the high-Fowler‘s position
a. On the left side
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.
The nurse is admitting a patient with possible respiratory failure and a high PaCO2. Which assessment information would the nurse immediately report to the health care provider?
a. The patient appears somnolent.
b. The patient reports feeling weak.
c. The patient‘s blood pressure is 164/98.
d. The patient‘s oxygen saturation is 90%.
a. The patient appears somnolent.
Rationale: Increasing somnolence will decrease the patient‘s respiratory rate and effort and further increase the PaCO 2 . 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.
A nurse is caring for a patient who is orally intubated and receiving mechanical ventilation.
To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care?
a. Elevate head of bed to 30 to 45 degrees.
b. Give enteral feedings at no more than 10 mL/hr.
c. Suction the endotracheal tube every 2 to 4 hours.
d. Limit the use of positive end-expiratory pressure.
a. Elevate head of bed to 30 to 45 degrees.
Rationale: Elevation of the head decreases the risk for aspiration. Positive end-expiratory pressure is frequently needed to improve oxygenation in patients receiving mechanical ventilation. Suctioning should be done only when the patient assessment indicates that it is necessary. Enteral feedings should provide adequate calories for the patient‘s high energy needs.
A patient admitted with acute respiratory failure is unable to clear thick secretions from the airway. Which nursing intervention would specifically address this patient problem?
a. Encourage use of the incentive spirometer.
b. Offer the patient fluids at frequent intervals.
c. Teach the patient the importance of ambulation.
d. Titrate oxygen level to keep O2 saturation above 93%.
b. Offer the patient fluids at frequent intervals.
Rationale: Thick, viscous secretions are hard to expel. Adequate fluid intake (2 to 3 L/day) keeps secretions thin and easier to remove, so the best action will be to encourage the patient to improve oral fluid intake. Patients should be instructed to use the incentive spirometer on a regular basis (e.g., every hour) to facilitate the clearance of the secretions. The other actions may be helpful in improving the patient‘s gas exchange, but they do not address the thick secretions that are causing the poor airway clearance.
A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department reporting shortness of breath on minimal exertion. Which assessment finding by the nurse would be 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 respiratory rate is 10 breaths/min.
d. The patient‘s pulse oximetry shows a 91% O 2 saturation.
c. The patient‘s respiratory rate is 10 breaths/min.
Rationale: A drop in respiratory rate in a patient with respiratory distress suggests the onset of fatigue and a high risk for respiratory arrest. Therefore, immediate action such as positive-pressure ventilation is needed. Patients who are experiencing respiratory distress frequently sit in the tripod position because it decreases the work of breathing. Crackles in the lung bases may be the baseline for a patient with COPD. An O2 saturation of 91% is common in patients with COPD and will provide adequate gas exchange and tissue oxygenation.
The nurse is caring for an older patient who was hospitalized 2 days earlier with community-acquired pneumonia. Which assessment information is most important to communicate to the health care provider?
a. Persistent cough of blood-tinged sputum
b. Scattered crackles in the posterior lung bases
c. Oxygen saturation 90% on 100% O2 by non-rebreather mask
d. Temperature 101.5F (38.6C) after 2 days of IV antibiotics
d. Temperature 101.5F (38.6C) after 2 days of IV antibiotics
Rationale: The patient‘s low SpO2 despite receiving a high fraction of inspired oxygen (FIO2 ) indicates the possibility of acute respiratory distress syndrome (ARDS). The patient‘s blood-tinged sputum and scattered crackles are not unusual in a patient with pneumonia, although they do need 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 a high O2 flowrate.
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 would 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. Use pulse oximetry to check the oxygen saturation.
Rationale: Agitation may be an early indicator of hypoxemia. The other actions may also be appropriate, depending on the findings about O2 saturation.
Which actions would the nurse use to reduce a patient‘s risk for ventilator-associated pneumonia (VAP)? (Select all that apply.)
a. Obtain arterial blood gases daily.
b. Provide a “sedation holiday” daily.
c. Give prescribed pantoprazole (Protonix).
d. Elevate the head of the bed to at least 30 degrees.
e. Provide oral care daily with chlorhexidine (0.12%) solution.
b. Provide a “sedation holiday” daily.
c. Give prescribed pantoprazole (Protonix).
d. Elevate the head of the bed to at least 30 degrees.
e. Provide oral care daily with chlorhexidine (0.12%) solution.
Rationale: These interventions are part of the ventilator bundle that is recommended to prevent VAP. Arterial blood gases may be done daily but are not always necessary and do not help prevent VAP.
