chapter 70

Question 1

To evaluate the effectiveness of prescribed therapies for a client with ventilatory failure,
which of the following diagnostic tests will be most useful to the nurse?
a. Chest x-rays
b. Pulse oximetry
c. Arterial blood gas (ABG) analysis
d. Pulmonary artery pressure monitoring

Answer 1

C
ABG analysis is most useful in this setting because ventilatory failure causes problems
with CO2 retention, and ABGs provide information about the PaCO2 and pH. The other
tests also may be done to help in assessing oxygenation or determining the cause of the
client’s ventilatory failure.

Question 2

The nurse is caring for a client who has been admitted with a pulmonary embolism and
notes a change in the client’s oxygen saturation (SpO2) from 94% to 88%. Which of the
following actions should the nurse implement?
a. Increase the oxygen flow rate.
b. Suction the client’s oropharynx.
c. Assist the client to cough and deep breathe.
d. Help the client to sit in a more upright position.

Answer 2

A
Increasing oxygen flow rate usually will improve oxygen saturation in clients 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.

Question 3

The nurse is caring for a client with respiratory failure who has a respiratory rate of 8/min
and a SpO2 of 89%. The client is increasingly lethargic. Which of the following actions
should the nurse anticipate?
a. Administration of 100% oxygen by non-rebreather mask
b. Endotracheal intubation and positive pressure ventilation
c. Insertion of a mini-tracheostomy with frequent suctioning
d. Initiation of bilevel positive pressure ventilation (BiPAP)

Answer 3

B

The client’s lethargy, low respiratory rate, and SpO2 indicate the need for mechanical
ventilation with ventilator-controlled respiratory rate. Administration of high flow oxygen
will not be helpful because the client’s respiratory rate is so low. Insertion of a
mini-tracheostomy will facilitate removal of secretions, but it will not improve the client’s
respiratory rate or oxygenation. BiPAP requires that the client initiate an adequate
respiratory rate to allow adequate gas exchange.

Question 4

The pulse oximetry for a client with right lower lobe pneumonia indicates an oxygen
saturation of 90%. The client has rhonchi, a weak cough effort, and complains of fatigue.
Which of the following actions is best for the nurse to take?
a. Position the client on the right side.
b. Place a humidifier in the client’s room.
c. Assist the client with staged coughing.
d. Schedule a 2-hour rest period for the client.

Answer 4

C
The client’s assessment indicates that assisted coughing is needed to help remove
secretions, which will improve oxygenation. A 2-hour rest period at this time may allow
the oxygen saturation to drop further. Humidification will not be helpful unless the
secretions can be mobilized. Positioning on the right side may cause a further decrease in
oxygen saturation because perfusion will be directed more toward the more poorly
ventilated lung.

Question 5

The nurse is caring for an obese client with left lower lobe pneumonia. Which of the
following positions should the nurse place the client in for optimal gas exchange?
a. Left lateral
b. Right lateral
c. Tripod position.
d. High Fowler’s position

Answer 5

B
The client should be positioned with the “good” lung in the dependent position to improve
the match between ventilation and perfusion. The obese client’s abdomen will limit
respiratory excursion when sitting in the high Fowler’s or tripod positions.

Question 6

The nurse is admitting a client who is in possible respiratory failure with a high PaCO2.
Which of the following assessment information will be of most concern to the nurse?
a. The client is somnolent.
b. The client’s SpO2 is 90%.
c. The client complains of weakness.
d. The client’s blood pressure is 162/94 mmHg.

Answer 6

A

Increasing somnolence will decrease the client’s respiratory rate and further increase the
PaCO2 and respiratory failure. Rapid action is needed to prevent respiratory arrest. An
SpO2 of 90%, weakness, and elevated blood pressure all require ongoing monitoring but
are not indicators of possible impending respiratory arrest.

Question 7

Chest physiotherapy is indicated for which of the following clients?
a. Takes a bronchodilator
b. Produces 40 mL of sputum per 24 hours
c. Has an increased PCO2 level
d. Is taking vancomycin

Answer 7

B
Chest physiotherapy is indicated in clients who produce more than 30 mL of sputum per
day or have evidence of severe atelectasis or pulmonary infiltrates. Vancomycin therapy is
not an indication for chest physio unless there is sputum present >30 mL/day. A client on a
bronchodilator does not necessarily require chest physio. An increased PCO2 level is not
an indication for chest physio.

Question 8

The nurse is caring for a client who develops increasing dyspnea and hypoxemia 2 days
after having cardiac surgery. To determine whether the client has acute respiratory
distress syndrome (ARDS) or pulmonary edema caused by left ventricular failure, the
nurse will anticipate assisting with which of the following actions?
a. Inserting a pulmonary artery catheter
b. Obtaining a ventilation–perfusion scan
c. Drawing blood for arterial blood gases
d. Positioning the client for a chest radiograph

Answer 8

A
Pulmonary artery wedge pressures are normal in the client with ARDS because the fluid in
the alveoli is caused by increased permeability of the alveolar-capillary membrane rather
than by the backup of fluid from the lungs (as occurs in cardiogenic pulmonary edema).
The other tests will not help in differentiating cardiogenic from noncardiogenic pulmonary
edema.

Question 9

Which of the following assessment findings by the nurse when caring for a client with
ARDS who is being treated with mechanical ventilation and high levels of positive
end-expiratory pressure (PEEP) indicates that the PEEP may need to be decreased?
a. The client has subcutaneous emphysema.
b. The client has a sinus bradycardia with a rate of 52.
c. The client’s PaO2 is 50 mm Hg and the SaO2 is 88%.
d. The client has bronchial breath sounds in both the lung fields.

Answer 9

A
The subcutaneous emphysema indicates barotrauma caused by positive pressure
ventilation and PEEP. Bradycardia, hypoxemia, and bronchial breath sounds are all
concerns and will need to be addressed, but they are not indications that PEEP should be
reduced.

Question 10

Which of the following statements by the nurse when explaining the purpose of positive
end-expiratory pressure (PEEP) to the family members of a client with ARDS is correct?
a. “PEEP will prevent fibrosis of the lung from occurring.”
b. “PEEP will push more air into the lungs during inhalation.”
c. “PEEP allows the ventilator to deliver 100% oxygen to the lungs.”
d. “PEEP prevents the lung air sacs from collapsing during exhalation.”

Answer 10

D
By preventing alveolar collapse during expiration, PEEP improves gas exchange and
oxygenation. PEEP will not prevent the fibrotic changes that occur with ARDS, push more
air into the lungs, or change the fraction of inspired oxygen (FIO2) delivered to the client.

Question 11

When prone positioning is used in the care of a client with acute respiratory distress
syndrome (ARDS), which of the following information obtained by the nurse indicates
that the positioning is effective?
a. The client’s PaO2 is 90 mm Hg, and the SaO2 is 92%.
b. Endotracheal suctioning results in minimal mucous return.
c. Sputum and blood cultures show no growth after 24 hours.
d. The skin on the client’s back is intact and without redness.

Answer 11

A
The purpose of prone positioning is to improve the client’s oxygenation as indicated by the
PaO2 and SaO2. The other information will be collected but does not indicate whether
prone positioning has been effective.

Question 12

The nurse obtains the vital signs for a client admitted 2 days ago with gram-negative
sepsis: temperature 38.4°C (101.1°F), blood pressure 90/56 mm Hg, pulse 92 beats/minute,
respirations 34/minute. Which of the following actions should the nurse take next?
a. Administer the scheduled IV antibiotic.
b. Give the PRN acetaminophen 650 mg.
c. Obtain oxygen saturation using pulse oximetry.
d. Notify the health care provider of the client’s vital signs.

Answer 12

C
The client’s increased respiratory rate in combination with the admission diagnosis of
gram-negative sepsis indicates that acute respiratory distress syndrome (ARDS) may be
developing. The nurse should check for hypoxemia, a hallmark of ARDS. The health care
provider should be notified after further assessment of the client. Administration of the
scheduled antibiotic and administration of acetaminophen also will be done, but they are
not the highest priority for a client who may be developing ARDS.

Question 13

To decrease the risk for ventilator-associated pneumonia, which of the following actions
should the nurse include in the plan of care for a client who requires intubation and
mechanical ventilation?
a. Avoid use of positive end-expiratory pressure (PEEP).
b. Suction every 2 hours.
c. Elevate head of bed to 45 degrees.
d. Give enteral feedings at no more than 10 mL/hour.

Answer 13

C
Elevation of the head decreases the risk for aspiration. PEEP is frequently needed to
improve oxygenation in clients receiving mechanical ventilation. Suctioning should be
done only when the client assessment indicates that it is necessary. Enteral feedings should
provide adequate calories for the client’s high energy needs.

Question 14

The nurse is caring for a client who has a nursing diagnosis of ineffective airway clearance
related to thick, secretions. Which of the following actions should the nurse include in the
plan of care?
a. Encourage use of the incentive spirometer.
b. Offer the client fluids at frequent intervals.
c. Teach the client the importance of coughing.
d. Increase oxygen level to keep O2 saturation >95%.

Answer 14

B
Since the reason for the poor airway clearance is the thick secretions, the best action will
be to encourage the client to improve oral fluid intake. The use of the incentive spirometer
should be more frequent in order to facilitate the clearance of the secretions. The other
actions also may be helpful in improving the client’s gas exchange, but they do not address
the thick secretions that are causing the poor airway clearance.

Question 15

The nurse is caring for a client with acute respiratory distress syndrome (ARDS) who is
intubated, receiving mechanical ventilation and has developed a pneumothorax. Which of
the following actions will the nurse anticipate taking?
a. Lower the positive end-expiratory pressure (PEEP).
b. Increase the fraction of inspired oxygen (FIO2).
c. Suction more frequently.
d. Increase the tidal volume.

Answer 15

A
Because barotrauma is associated with high airway pressures, the level of PEEP should be
decreased. The other actions will not decrease the risk for pneumothorax.

Question 16

After receiving change-of-shift report, which of the following clients should the nurse
assess first?
a. A client with cystic fibrosis who has thick, green-coloured sputum
b. A client with pneumonia who has coarse crackles in both lung bases
c. A client with emphysema who has an oxygen saturation of 91% to 92%
d. A client with septicemia who has intercostal and suprasternal retractions

Answer 16

D
This client’s history of septicemia and laboured breathing suggest the onset of ARDS,
which will require rapid interventions such as administration of oxygen and use of positive
pressure ventilation. The other clients also should be assessed as quickly as possible, but
their assessment data are typical of their disease processes and do not suggest deterioration
in their status.

Question 17

The nurse is admitting a client with chronic obstructive pulmonary disease (COPD) who
has shortness of breath and dyspnea. Which of the following assessment findings is most
important to report to the health care provider?
a. The client has bibasilar lung crackles.
b. The client is sitting in the tripod position.
c. The client’s respiratory rate has decreased from 30 to 10 breaths/minute.
d. The client’s pulse oximetry indicates an O2 saturation of 91%.

Answer 17

C
A decrease in respiratory rate in a client 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. Clients 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 client with COPD. An oxygen saturation of 91% is
common in clients with COPD and will provide adequate gas exchange and tissue
oxygenation.

Question 18

The nurse is assessing a client with chronic lung disease and finds a sudden onset of
agitation and confusion. Which of the following actions should the nurse take first?
a. Check pupil reaction to light.
b. Notify the health care provider.
c. Attempt to calm and reassure the client.
d. Assess oxygenation using pulse oximetry.

Answer 18

D
Since agitation and confusion are frequently the initial indicators of hypoxemia, the
nurse’s initial action should be to assess oxygen saturation. The other actions also are
appropriate, but assessment of oxygenation takes priority over other assessments and
notification of the health care provider.

Question 19

The nurse is caring for a client who came to the emergency department with acute
respiratory distress. Which of the following information requires the most rapid action by
the nurse?
a. Respiratory rate is 32 breaths/minute.
b. Pattern of breathing is shallow.
c. The client’s PaO2 is 45 mm Hg.
d. The client’s PaCO2 is 34 mm Hg.

Answer 19

C
The PaO2 indicates severe hypoxemia and respiratory failure. Rapid action is needed to
prevent further deterioration of the client. Although the shallow breathing, rapid
respiratory rate, and low PaCO2 also need to be addressed, the most urgent problem is the
client’s poor oxygenation.

Question 20

The nurse is caring for a client who was hospitalized 2 days earlier with aspiration
pneumonia. Which of the following assessment information is most important to
communicate to the health care provider?
a. Cough that is productive of blood-tinged sputum
b. Scattered crackles throughout the posterior lung bases
c. Temperature of 38.6°C (101.5°C) after 2 days of IV antibiotic therapy
d. Oxygen saturation (SpO2) has dropped to 90% with administration of 100% O2 by
non-rebreather mask

Answer 20

D
The client’s low SpO2 despite receiving a high fraction of inspired oxygen (FIO2) indicates
the possibility of acute respiratory distress syndrome (ARDS). The client’s blood-tinged
sputum and scattered crackles are not unusual in a client with pneumonia, although they
do require continued monitoring. The continued temperature elevation indicates a possible
need to change antibiotics, but this is not as urgent a concern as the progression toward
hypoxemia despite an increase in O2 flow rate.

Question 21

The nurse is caring for a client with hypoxemia and a PaO2/FiO2 ratio of 170 while being
administered oxygen 8 L/minute via mask. Which of the following information is accurate
in relation to the client’s situation?
a. Is at risk for ARDS
b. Also has an increased PaCO2 level
c. Should be prepared for mechanical ventilation
d. Requires packed red cells as soon as possible

Answer 21

A
Hypoxemia and a PaO2/FiO2 ratio below 200 despite increased FiO2 by mask, cannula, or
endotracheal tube are hallmarks of ARDS. ABGs may initially demonstrate a normal or
decreased PaCO2 despite severe dyspnea and hypoxemia. Hypercapnia signifies that
hypoventilation is occurring and the client is no longer able to maintain the level of
ventilation needed to provide optimum gas exchange.

Question 22

A client with ARDS who is receiving mechanical ventilation using synchronized
intermittent mandatory ventilation (SIMV) has settings of fraction of inspired oxygen
(FIO2) 80%, tidal volume 500, rate 18, and positive end-expiratory pressure (PEEP) 5 cm.
Which of the following assessment findings is most important for the nurse to report to the
health care provider?
a. Oxygen saturation 99%
b. Client respiratory rate 22 breaths/minute
c. Crackles audible at lung bases
d. Apical pulse rate 104 beats/minute

Answer 22

A
The FIO2 of 80% increases the risk for oxygen toxicity. Since the client’s O2 saturation is
99%, a decrease in FIO2 is indicated to avoid toxicity. The other client data would be
typical for a client with ARDS and would not need to be urgently reported to the health
care provider.

Question 23

The nurse is caring for a client with chronic hypercapnia and is to receive supplemental
oxygen. Which of the following prescribed actions should the nurse implement?
a. Venturi mask at 48%
b. Nasal cannula at 1–2 L/minute
c. Noninvasive ventilation
d. Face mask at 4–5 L/minute

Answer 23

B
Clients with chronic hypercapnia should receive O2 through a low-flow device such as a
nasal cannula at 1–2 L/minute or a Venturi mask at 24% to 28%.