Exam 1 Tryhard 220 Flashcards
You’re providing care to a patient who is being treated for aspiration pneumonia. The patient is on a 100% non-rebreather mask. Which finding below is a HALLMARK sign and symptom that the patient is developing acute respiratory distress syndrome (ARDS)?
A. The patient is experiencing bradypnea.
B. The patient is tired and confused.
C. The patient’s PaO2 remains at 45 mmHg.
D. The patient’s blood pressure is 180/96.
C. The patient’s PaO2 remains at 45 mmHg.
A hallmark sign and symptom found in ARDS is refractory hypoxemia. This is where that although the patient is receiving a high amount of oxygen (here a 100% non-rebreather mask) the patient is STILL hypoxic. Option C is the answer because it states the patient’s arterial oxygen level is remaining at 45 mmHg (a normal is 80 mmHg but when treating patients with ARDS a goal is at least 60 mmHg). Yes, the patient can be tired and confused from a low oxygen level BUT this question wants to know the HALLMARK sign and symptom.
During the exudative phase of acute respiratory distress syndrome (ARDS), the patient’s lung cells that produce surfactant have become damaged. As the nurse you know this will lead to?
A. bronchoconstriction
B. atelectasis
C. upper airway blockage
D. pulmonary edema
B. atelectasis
Surfactant decreases surface tension in the lungs. Therefore, the alveoli sacs will stay stable when a person exhales (hence the sac won’t collapse). If there is a decrease in surfactant production this creates an unpredictable alveoli sac that can easily collapse, hence a condition called ATELETASIS will occur (collapse of the lung tissue) when there is a decrease production in surfactant.
A patient has been hospitalized in the ICU for a near drowning event. The patient’s respiratory function has been deteriorating over the last 24 hours. The physician suspects acute respiratory distress syndrome. A STAT chest x-ray is ordered. What finding on the chest x-ray is indicative of ARDS?
A. infiltrates only on the upper lobes
B. enlargement of the heart with bilateral lower lobe infiltrates
C. white-out infiltrates bilaterally
D. normal chest x-ray
C. white-out infiltrates bilaterally
You’re providing care to a patient who was just transferred to your unit for the treatment of ARDS. The patient is in the exudative phase. The patient is ordered arterial blood gases. The results are back. Which results are expected during this early phase of acute respiratory distress syndrome that correlates with this diagnosis?
A. PaO2 40, pH 7.59, PaCO2 30, HCO3 23
B. PaO2 85, pH 7.42, PaCO2 37, HCO3 26
C. PaO2 50, pH 7.20, PaCO2 48, HCO3 29
D. PaO2 55, pH 7.26, PaCO2 58, HCO3 19
A. PaO2 40, pH 7.59, PaCO2 30, HCO3 23
This option demonstrates respiratory alkalosis. In the early stages of ARDS (exudative) the patient will start to enter in respiratory alkalosis. The patient starts to have tachypnea (the body’s way of trying to increase the oxygen level but it can’t). They will have a very low PaO2 level (normal PaO2 is 80 mmHg), the blood pH will become high (normal is 7.35-7.45) (alkalotic). In the late stage, the patient can enter into respiratory acidosis.
Which patient below is at MOST risk for developing ARDS and has the worst prognosis?
A. A 52-year-old male patient with a pneumothorax.
B. A 48-year-old male being treated for diabetic ketoacidosis.
C. A 69-year-old female with sepsis caused by a gram-negative bacterial infection.
D. A 30-year-old female with cystic fibrosis.
C. A 69-year-old female with sepsis caused by a gram-negative bacterial infection.
Sepsis is the MOST common cause of ARDS because of systemic inflammation experienced. This is also true if the cause of the sepsis is a gram-negative bacterium (this also makes the infection harder to treat…hence poor prognosis). With sepsis, the immune cells that are present with the inflammation travel to the lungs and damage the alveolar capillary membrane leading to fluid to leak in the alveolar sacs.
As the nurse you know that acute respiratory distress syndrome (ARDS) can be caused by direct or indirect lung injury. Select below all the INDIRECT causes of ARDS:
A. Drowning B. Aspiration C. Sepsis D. Blood transfusion E. Pneumonia F. Pancreatitis
C. Sepsis
D. Blood transfusion
F. Pancreatitis
Indirect causes are processes that can cause inflammation OUTSIDE of the lungs….so the issue arises somewhere outside the lungs. Therefore, sepsis (infection…as long as it is outside the lungs), blood transfusion, and pancreatitis are INDIRECT causes. Drowning, aspiration, and pneumonia are issues that arise in the lungs (therefore, they are DIRECT causes of lung injury).
A patient is on mechanical ventilation with PEEP (positive end-expiratory pressure). Which finding below indicates the patient is developing a complication related to their therapy and requires immediate treatment?
A. HCO3 26 mmHg
B. Blood pressure 70/45
C. PaO2 80 mmHg
D. PaCO2 38 mmHg
B. Blood pressure 70/45
Mechanical ventilation with PEEP can cause issues with intrathoracic pressure and decrease the cardiac output (watch out for a low blood pressure) along with hyperinflation of the lungs (possible pneumothorax or subq emphysema which is air that escapes into the skin because the lungs are leaking air).
You are caring for a patient with acute respiratory distress syndrome. As the nurse you know that prone positioning can be beneficial for some patients with this condition. Which findings below indicate this type of positioning was beneficial for your patient with ARDS?
A. Improvement in lung sounds
B. Development of a V/Q mismatch
C. PaO2 increased from 59 mmHg to 82 mmHg
D. PEEP needs to be titrated to 15 mmHg of water
A. Improvement in lung sounds
C. PaO2 increased from 59 mmHg to 82 mmHg
Prone positioning helps improve PaO2 (82 mmHg is a good finding) without actually giving the patient high concentrations of oxygen. It helps improves perfusion and ventilation (hence correcting the V/Q mismatch). In this position, the heart is no longer laying against the posterior part of the lungs (improves air flow…hence improvement of lung sounds) and it helps move secretions from other areas that were fluid filled and couldn’t move in the supine position, hence helping improve atelectasis.
A nurse must position the patient prone after his diagnosis of acute respiratory distress syndrome (ARDS). Which of the following is a benefit of using this position? Select all that apply.
A.Decreased atelectasis
B.Reduced need for endotracheal intubation
C.Mobilization of secretions
D.Decreased pleural pressure
E.Increased response to corticosteroid therapy
A.decreased atelectasis
C.mobilization of secretions
D. decreased pleural pressure
Decreased atelectasis”, “Mobilization of secretions” and “Decreased pleural pressure” are correct. Prone positioning, or placing the patient face down with the head turned to the side, helps with pulmonary function in the patient diagnosed with ARDS. When the patient is placed in prone position, the heart and diaphragm are not pressing against the lungs, which means that pleural pressure is reduced. When there is less pressure exerted on the lungs, atelectasis decreases. Studies have shown that many patients in the prone position have increased lung secretions, which improves oxygenation.
A nurse walks in to a client who is in respiratory distress. The client has tracheal deviation to the right side. The nurse knows to prepare for which of the following emergent procedures?
A.Chest tube insertion on the left side.
B.Chest tube insertion on the right side.
C.Intubation
D.Tracheostomy
A. chest tube insertion on left side
Tracheal deviation indicates a pneumothorax, the direction of the deviation indicates the side the pneumothorax is on. If the trachea is deviating to the right, then the pneumo is on the left. The treatment for this is a chest tube on the side of trhe deflated lung.
A nurse is caring for a patient with ARDS. Which of the following clinical indicators would signify that this client is in respiratory failure? Select all that apply.
A.Pulse oximetry of 94% on room air b.A PaO2 level below 60 mmHg C.An ABG pH level of 7.35 D.A pCO2 level over 50 mmHg E.A respiratory rate of over 16/minute
B.PaO2 below 60
D.PCO2 over 50
respiratory diseases can cause such compromise that the patient will suffer symptoms; however, there are certain clinical indicators that can clarify whether the patient is actually in respiratory failure. Clinical indicators of respiratory failure include pulse oximetry of less than 91% on room air, PaO2 level less than 60 mmHg, and a pCO2 level of over 50 mmHg.
A patient who has recovered from ARDS in the ICU is now malnourished and has lost a significant amount of weight. The physician orders TPN to add nutrition for the patient, who then develops re-feeding syndrome. Which of the following signs or symptoms would the nurse expect to see with re-feeding syndrome? Select all that apply.
A.Impaired mental status B.Insulin resistance C.Seizures D.Persistent weight loss E.Constipation
A.impaired mental status
B.insulin resistance
C.seizures
“Impaired mental status”, “Insulin resistance” and “Seizures” are correct. Re-feeding syndrome can occur as a response to nutrient reintroduction after a period of starvation. When an extremely malnourished patient receives TPN, the body has to adjust to receiving nutrients again, which can cause shifts in electrolytes in the body. These shifts in electrolytes can result in sudden and often fatal complications. Signs and symptoms of re-feeding syndrome include confusion and impaired mental status, insulin resistance, seizures, coma and death.
A 25-year-old patient in the ICU is being treated for acute respiratory distress syndrome (ARDS). The patient is on a ventilator and requires 80 percent FiO2. Which information would the nurse most likely need to report about the patient to the respiratory therapist working with her?
A.The patient needs an arterial blood gas drawn
B.The patient needs endotracheal suctioning
C.The patient needs more oxygen because of his saturations
D.The patient needs a hemoglobin level drawn
A.The patient needs an arterial blood gas drawn
Respiratory therapists have many duties in the healthcare facility and they frequently monitor and work out many technical details of the patients care when a ventilator is being used. A respiratory therapist would most likely change the ventilator settings but the nurse is able to increase the oxygen level on the ventilator and the nurse can suction the patient. It is often part of the job description for a respiratory therapist to draw arterial blood gas levels.
The nurse is caring for a client with suspected acute respiratory distress syndrome (ARDS). Which symptom of ARDS should the nurse anticipate will appear within 24 to 48 hours after the initial insult? (Select all that apply.)
A.Shortness of breath B.Rapid breathing C.Fluid imbalance D.Chest x-ray clear of infiltrates E.Arterial blood gases varying from normal limits
A.Shortness of breath
B.Rapid breathing
D.Chest x-ray clear of infiltrates
Rapid breathing and shortness of breath are two early symptoms of ARDS that manifest in the first day or two after the initial injury. On chest x-ray, no infiltrates will be noted in the early stages and lung sounds will be clear. Fluid imbalance and abnormal arterial blood gas levels will be noted later in the disease process.
A client is diagnosed with acute respiratory distress syndrome (ARDS). The client’s spouse asks the nurse what caused ARDS. Which etiology of indirect injury to the lungs should the nurse include in the response? (Select all that apply.)
A.Smoke inhalation B.Systemic sepsis C.Fat embolism D.Multiple blood transfusions E.Pancreatitis
B.Systemic sepsis
D.Multiple blood transfusions
E.Pancreatitis
Pancreatitis, systemic sepsis, and multiple blood transfusions are causes of indirect injury to the lungs. Smoke inhalation and fat embolisms are causes of direct injury to the lungs.
The nurse is caring for a client who had an episode of near-drowning 5 days ago. This morning, the nurse noted rhonchi in the lower lung lobes on auscultation. Which action by the nurse is best?
A.Documenting the findings as normal
B.Preparing for intubation
C.Notifying the healthcare provider
D.Monitoring vital signs and oxygen saturation every 2 hours
C.Notifying the healthcare provider
Changes in lung sounds after a pulmonary injury, like near-drowning, can indicate that the client is developing acute respiratory distress syndrome (ARDS). The nurse should notify the healthcare provider of the change in the client’s condition. Intubation is not necessary unless the client is in respiratory distress. Rhonchi on auscultation are not a normal finding and require the nurse to take action. It is not appropriate for the nurse to simply monitor the client without taking action to prevent a worsening of the client’s condition.
The nurse is caring for a client with respiratory acidosis secondary to end-stage acute respiratory distress syndrome (ARDS). Which result should the nurse anticipate on the arterial blood gas?
A.High PaO2 and low PaCO2
B.Low PaO2 and low PaCO2
C.Low PaO2 and high PaCO2
D.High PaO2 and high PaCO2
C. Low PaO2 and high PaCO2
In end-stage ARDS, physiological changes in the alveoli prevent CO2 from diffusing across the alveolar membranes, causing the PaCO2 to rise and PaO2 to fall. Eventually, respiratory distress and respiratory failure will develop, and without further intervention, death will result.
A client who is diagnosed with acute respiratory distress syndrome (ARDS) requires mechanical ventilation. Which ventilator mode should the nurse expect to implement to promote pressure throughout the respiratory cycle?
A.Sensitivity
B.Positive end-expiratory pressure (PEEP)
C.Flow rate
D.Tidal volume (TV)
Positive end-expiratory pressure (PEEP)
Positive end-expiratory pressure can be used with many different ventilator settings and maintains positive pressure in between breaths and during exhalation, preventing collapse of the alveoli. Flow rate, sensitivity, and tidal volume are settings that can be adjusted on the ventilator.
The nurse is caring for a client with acute respiratory distress syndrome (ARDS) who needs an artificial airway to assist in maintaining an open airway. Which airway will the nurse plan to reposition every 8 hours while providing care?
A.Endotracheal
B.Nasopharyngeal
C.Oropharyngeal
D.Tracheostomy
B. Nasopharyngeal
The nasopharyngeal airway must be repositioned every 8 hours to prevent necrosis of the mucosa. The other airways will not require this intervention from the nurse.
During assessment of a client with acute respiratory distress syndrome (ARDS), the nurse notes an oxygen saturation of 78% and a respiratory rate of 28 breaths/min. The nurse notifies the healthcare provider and should prepare for intubation using which type of airway?
A.Tracheostomy
B.Endotracheal tube
C.Oropharyngeal airway
D.Nasopharyngeal airway
B.Endotracheal tube
An endotracheal tube is the most common type of airway placed, especially in emergency situations in which mechanical ventilation is required. This client would not initially need a tracheostomy, because it is an airway used for long-term support. Oropharyngeal and nasopharyngeal airways are only used when the upper air passages are at risk of becoming obstructed by secretions or the tongue.
The nurse is assessing an older adult client with acute respiratory distress syndrome (ARDS). Which assessment finding indicates an early sign of hypoxemia for this client? (Select all that apply.)
A.Agitation B.Tachypnea C.Confusion D.Anxiety E.Dyspnea
A.Agitation
C.Confusion
D.Anxiety
Anxiety, agitation, and confusion are assessment findings that older adult clients experience as early signs of hypoxemia. While dyspnea and tachypnea may indicate hypoxemia, these are not early symptoms the nurse will find during the assessment process.
The nurse is providing care to a client with acute respiratory distress syndrome (ARDS). Which independent intervention should the nurse prepare to perform for this client? (Select all that apply.)
A.Maintain the head of the bed at 30 degrees.
B.Recommend a prone position to facilitate oxygenation.
C.Prescribe analgesia for pain.
D.Order a Foley catheter to monitor urine output.
E.Auscultate heart and lung sounds.
A.Maintain the head of the bed at 30 degrees.
B.Recommend a prone position to facilitate oxygenation.
E.Auscultate heart and lung sounds.
The nurse can independently auscultate heart and lung sounds, maintain the head of the bed at 30 degrees, and recommend prone positioning to facilitate oxygenation. It is outside the scope of nursing practice for the nurse to prescribe analgesics for pain or order a Foley catheter to monitor urine output.
The nurse is planning care for a client with acute respiratory distress syndrome (ARDS). Which independent nursing intervention should the nurse include in the care of this client? (Select all that apply.)
A.Maintain the head of the bed at less than 30 degrees.
B.Obtain a sputum culture.
C.Prescribe surfactant therapy.
D.Position the client in a prone position for 60 minutes five times a day.
E.Suction the airway as needed.
B.Obtain a sputum culture
E.Suction the airway as needed
Nursing interventions for a client who is suffering from ARDS include suctioning and obtaining sputum cultures. It is outside the scope of nursing practice to prescribe surfactant therapy. The head of the bed should be maintained at greater than 30 degrees. Prone positioning is recommended for 30 minutes three to four times per day.
The nurse is caring for a client who is in the process of weaning off of mechanical ventilation. Which assessment finding should the nurse report to the healthcare provider? (Select all that apply.)
A.Abdominal breathing B.Oxygen saturation level of 98% C.Respiratory rate of 18 beats/min D.Pallor E.Agitation
A)Abdominal breathing
D)Pallor
E)Agitation
Assessment findings that may indicate dysfunctional weaning include pallor or cyanosis, agitation or apprehension, presence of abdominal breathing, abnormal vital signs, and decreased level of consciousness. A respiratory rate of 18 beats/min and oxygen saturation level of 98% are both within normal limits and do not need to be reported.