Lewis Chapter 70: Respiratory Failure and ARDS

Question 1

The nurse is admitting a patient with asthma who is in acute respiratory distress. The nurse auscultates the patient’s lungs and notes cessation of inspiratory wheezing. The patient has not yet received any medication. What of the following explanations is most likely related to this clinical presentation?

A. Spontaneous resolution of the acute asthma attack
B. An acute development of bilateral pleural effusions
C. Airway constriction requiring intensive interventions
D. Overworked intercostal muscles resulting in poor air exchange

Answer 1

C. Airway constriction requiring intensive interventions

When the patient in respiratory distress has inspiratory wheezing that then ceases, it is an indication of airway obstruction and requires emergency action to restore the airway.

Question 2

The nurse is caring for a patient who is admitted with a barbiturate overdose. The patient is comatose with the following vital signs: BP 90/60, apical pulse 110, and respiratory rate 8/minute. Based upon these initial assessment findings, the nurse recognizes that the patient is at risk for which of the following types of respiratory failure?

A. Hypoxemic respiratory failure related to shunting of blood
B. Hypoxemic respiratory failure related to diffusion limitation
C. Hypercapnic respiratory failure related to alveolar hypoventilation
D. Hypercapnic respiratory failure related to increased airway resistance

Answer 2

C. Hypercapnic respiratory failure related to alveolar hypoventilation

The patient’s respiratory rate is decreased as a result of barbiturate overdose, which causes respiratory depression. The patient is at risk for hypercapnic respiratory failure resulting from the decreased respiratory rate and thus decreased CO2 exchange.

Question 3

The nurse is providing care for an older patient who is experiencing low partial pressure of oxygen in arterial blood (PaO2) as a result of worsening left-sided pneumonia. Which of the following interventions should the nurse use to help the patient mobilize secretions?

A. Augmented coughing or huff coughing
B. Positioning the patient side-lying on their left side
C. Frequent and aggressive nasopharyngeal suctioning
D. Application of noninvasive positive pressure ventilation (NIPPV)

Answer 3

A. Augmented coughing or huff coughing

Augmented coughing (quad coughing) and huff coughing techniques may aid the patient in the mobilization of secretions. If positioned side-lying, the patient should be positioned on their right side (good lung down). Suctioning may be indicated, but should always be performed cautiously because of the risk of hypoxia. Noninvasive positive pressure ventilation (NIPPV) is inappropriate in the treatment of patients with excessive secretions.

Question 4

The nurse is caring for a patient who is experiencing acute respiratory distress syndrome (ARDS) as a result of sepsis. Which of the following measures would most likely be implemented to maintain cardiac output?

A. Administer crystalloid fluids or colloid solutions.
B. Position the patient in the Trendelenburg position.
C. Perform chest physiotherapy and assist with staged coughing.
D. Place the patient on fluid restriction and administer diuretics.

Answer 4

A. Administer crystalloid fluids or colloid solutions

Low cardiac output may necessitate the administration of crystalloid fluids or colloid solutions in addition to lowering positive end-expiratory pressure (PEEP) or administering inotropes. The Trendelenburg position (not recommended to treat hypotension) and chest physiotherapy are unlikely to relieve decreased cardiac output, and fluid restriction and diuresis would be inappropriate interventions as they could potentially further decrease cardiac output.

Question 5

For which of the following patients would noninvasive positive pressure ventilation (NIPPV) be an appropriate intervention to promote oxygenation?

A. A patient whose cardiac output and blood pressure are unstable
B. A patient whose respiratory failure is due to a head injury with loss of consciousness
C. A patient with a diagnosis of cystic fibrosis and who is currently producing copious secretions
D. A patient who is experiencing respiratory failure as a result of the progression of myasthenia gravis

Answer 5

D. A patient who is experiencing respiratory failure as a result of the progression of myasthenia gravis

Noninvasive positive pressure ventilation (NIPPV) is most effective in treating patients with respiratory failure resulting from chest wall and neuromuscular disease. It is not recommended in patients who are experiencing cardiac instability, decreased level of consciousness, or excessive secretions.

Question 6

The nurse is aware of the value of using a mini-tracheostomy to facilitate suctioning when patients are unable to independently mobilize their secretions. For which of the following patients is the use of a mini-tracheostomy indicated?

A. A patient whose recent ischemic stroke has resulted in the loss of their gag reflex
B. A patient who requires long-term mechanical ventilation as the result of a spinal cord injury
C. A patient whose increased secretions are the result of community-acquired pneumonia
D. A patient with a head injury who has developed aspiration pneumonia after their family insisted on spoon-feeding them

Answer 6

C. A patient whose increased secretions are the result of community-acquired pneumonia

It is probably appropriate to suction a patient with pneumonia using a mini-tracheostomy if blind suctioning is ineffective or difficult. An absent or compromised gag reflex, long-term ventilation, and a history of aspiration contraindicate the use of a mini-tracheostomy.

Question 7

What is an early sign of acute respiratory failure?

a. Coma

b. Cyanosis

c. Restlessness

d. Paradoxical breathing

Answer 7

C.

Question 8

Which type of oxygen delivery system should be chosen for clients in acute respiratory failure?

a. A low-flow device, such as a nasal cannula

b. One that should correct the partial pressure of oxygen in arterial blood (PaO2) to a normal level as quickly as possible

c. Positive-pressure ventilation to prevent CO2 narcosis

d. One that should maintain the PaO2 at 60 mm Hg or higher at the lowest fraction of inspired oxygen (FiO2) possible

Answer 8

D.

Question 9

What are the early clinical manifestations of ARDS?

a. Dyspnea and tachypnea

b. Cyanosis and apprehension

c. Hypotension and tachycardia

d. Respiratory distress and frothy sputum

Answer 9

A.

Question 10

How is fluid balance maintained in clients with ARDS?

a. Hydration with colloids

b. Administration of surfactant

c. Mild fluid restriction and diuretics as necessary

d. Keeping the hemoglobin at levels of 9.5 mmol/L (15 g/dL)

Answer 10

C.

Question 11

Which of the following is designed to prevent barotrauma in clients with ARDS?

a. Increasing positive end-expiratory pressure (PEEP)

b. Increasing the tidal volume

c. Permissive hypercapnia

d. Pressure support ventilation

Answer 11

C.

Question 12

Which factor distinguishes hypercapnic respiratory failure from hypoxemic respiratory failure?

A. Low oxygen saturation levels despite oxygen administration

B. Acidemia that the body is unable to compensate for

C. Respiratory rate greater than 30 breaths/min

D. Heart rate increases greater than 100 beats/min

Answer 12

B. Acidemia that the body is unable to compensate for

Hypercapnic respiratory failure is PaCO2>48 mm Hg in combination with acidemia (arterial pH <7.35). The body cannot compensate for the acidemia.

Question 13

Which action would the nurse take first when assessing a patient with chronic lung disease who has had a sudden onset of agitation and confusion?

A. Check pupil reaction to light.

B. Notify the health care provider.

C. Attempt to calm and reassure the patient.

D. Assess oxygenation using pulse oximetry.

Answer 13

D. Assess oxygenation using pulse oximetry.

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 14

Which action by a patient indicates they are having difficulty breathing?

A. Reporting one-pillow orthopnea

B. Speaking a sentence before breathing

C. Exhibiting an inspiratory-to-expiratory (I:E) ratio of 1:2

D. Paradoxical breathing

Answer 14

D. Paradoxical breathing

Paradoxical breathing indicates severe distress. The thorax and abdomen normally move outward on inspiration and inward on exhalation. During paradoxical breathing, the abdomen and chest move in the opposite manner, and the pattern results from maximal use of the accessory muscles of respiration.

Question 15

Which diagnostic study would the nurse expect to be ordered if the health care provider wants to rule out cardiac as the cause of a patient respiratory failure due to pulmonary edema?

A. Pulmonary wedge pressures

B. Arterial blood gas (ABG) measurements

C. Pulmonary function tests

D. An arterial line

Answer 15

A. Pulmonary wedge pressures

A pulmonary artery wedge pressure measures the left atrial pressure. A pulmonary catheter is “wedged” with a balloon in the pulmonary arterial branch to measure the pressure. If the reading is less than 18 mmHg it indicates this is not a cardiac issue.

Question 16

Which arterial blood gas (ABG) result in a patient with chronic lung disease would likely indicate acute respiratory failure?

A. PaO2 52 mm Hg; PaCO2 56 mm Hg; pH 7.4

B. PaO2 48 mm Hg; PaCO2 54 mm Hg; pH 7.38

C. PaO2 46 mm Hg; PaCO2 52 mm Hg; pH 7.36

D. PaO2 50 mm Hg; PaCO2 54 mm Hg; pH 7.28

Answer 16

D. PaO2 50 mm Hg; PaCO2 54 mm Hg; pH 7.28

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

Question 17

Which statement best summarizes the desired outcome for the selection of an oxygen delivery system for patients in acute respiratory failure?

A. Using a low-flow device, such as a nasal cannula, is best to avoid oxygen toxicity.

B. The device should correct the PaO2 to a normal level as quickly as possible.

C. Maintenance of PaO2 at ≥60 mm Hg is best at the lowest O2 concentration possible.

D. The device should administer positive-pressure ventilation to decrease work of breathing.

Answer 17

C. Maintenance of PaO2 at ≥60 mm Hg is best at the lowest O2 concentration possible.

The selected oxygen delivery system must maintain PaO2 at 55 to 60 mm Hg and SaO2 at 90% or greater at the lowest oxygen concentration possible.

Question 18

Which nursing intervention would best help mobilize secretions in a patient with muscle weakness?

A. Application of noninvasive positive-pressure ventilation (NIPPV)

B. Frequent and aggressive nasopharyngeal suctioning

C. Performing an augmented coughing technique

D. Positioning the patient to lie on their side

Answer 18

C. Performing an augmented coughing technique

The augmented coughing technique may aid the patient in the mobilization of secretions.

Question 19

Which information about a patient who is receiving cisatracurium (Nimbex) to prevent asynchronous breathing with the positive-pressure ventilator requires action by the nurse?

A. No sedative has been ordered for the patient.

B. The patient does not respond to verbal stimulation.

C. There is no cough or gag reflex when the patient is suctioned.

D. The patient’s oxygen saturation remains between 90 and 93%.

Answer 19

A. No sedative has been ordered for the patient.

Neuromuscular blockade treatment is extremely anxiety provoking, so it is essential that patients who are receiving neuromuscular blockade receive concurrent sedation and analgesia.

Question 20

For which reason is hemodynamic monitoring instituted in severe respiratory failure?

A. To detect VQ mismatches

B. To evaluate cardiac status and blood flow to tissues

C. To continuously measure the vital signs

D. To evaluate oxygenation and ventilation status

Answer 20

B. To evaluate cardiac status and blood flow to tissues

Hemodynamic monitoring with a pulmonary artery catheter is instituted in severe respiratory failure to determine the amount of blood flow to tissues and the response of the lungs and heart to hypoxemia. Continuous blood pressure (BP) monitoring may be performed but BP reflects cardiac activity, which can be determined by the pulmonary artery catheter findings.

Question 21

Which patient manifestation is likely to result in hypercapnic respiratory failure?

A. Slow, shallow respirations because of sedative overdose

B. Large airway resistance as a result of severe bronchospasm

C. Poorly ventilated areas of the lung caused by pulmonary edema

D. Rapid, deep respirations in response to pneumonia

Answer 21

A. Slow, shallow respirations because of sedative overdose

Hypercapnic respiratory failure is associated with alveolar hypoventilation with increases in alveolar and arterial CO2 and often is caused by problems outside the lungs. A patient with slow, shallow respirations is not exchanging enough gas volume to eliminate CO2.

Question 22

Which statement explains why a patient who presented to the emergency room with acute exacerbation remains in respiratory distress over the next hour, but their respiratory rate eventually slows?

A. The patient is developing respiratory muscle fatigue.

B. The respirations are exchanging oxygen and carbon dioxide more efficiently.

C. The anxiety level of the patient is lessening.

D. The body has compensated by retaining sodium bicarbonate.

Answer 22

A. The patient is developing respiratory muscle fatigue.

A rapid respiratory rate requires a substantial amount of work. Change from a rapid rate to a slower rate in a patient in acute respiratory distress suggests extreme progression of respiratory muscle fatigue and increased probability of respiratory arrest.

Question 23

Which nursing action is appropriate for a patient in acute respiratory failure?

A. Administer 100% oxygen to an intubated patient until the pathology has resolved.

B. Provide chest physical therapy if the patient produces more than 30 mL of sputum per day.

C. Use continuous positive airway pressure (CPAP) if the patient has weak or absent respirations.

D. Administer packed red blood cells to maintain the hemoglobin level at 7 mmol/L or higher.

Answer 23

B. Provide chest physical therapy if the patient produces more than 30 mL of sputum per day.

Chest physical therapy is indicated for patients who produce more than 30 mL of sputum per day or have evidence of atelectasis or pulmonary infiltrates.

Question 24

For which patient would noninvasive positive pressure ventilation (NIPPV) be an appropriate intervention to promote oxygenation?

A. Patient whose cardiac output and blood pressure are unstable

B. Patient whose respiratory failure is caused by a head injury with loss of consciousness

C. Patient with a diagnosis of cystic fibrosis and who is producing copious secretions

D. Patient who is experiencing respiratory failure because of the progression of myasthenia gravis

Answer 24

D. Patient who is experiencing respiratory failure because of the progression of myasthenia gravis

NIPPV is most effective in treating patients with respiratory failure due to chest wall and neuromuscular disease.

Question 25

Which complication occurs during the exudative phase due to damage of the alveolar cells and the decreased production of surfactant?

A. Bronchoconstriction

B. Respiratory acidosis

C. Pulmonary edema

D. Atelectasis

Answer 25

D. Atelectasis

Surfactant decreases surface tension in the lungs. When there are adequate amounts of surfactant the alveoli remain stable and will not collapse. When there is a decrease in surfactant production, this causes the alveoli sac to become unpredictable and they can easily collapse resulting in atelectasis.

Question 26

Which finding is a hallmark manifestation that a patient with pneumonia who is on a 100% non-rebreather mask is developing acute respiratory distress syndrome (ARDS)?

A. The patient is tired and confused.

B. The PaO2 level is at 46 mm Hg despite oxygen use.

C. Respiratory rate is 16–18 breaths/min.

D. Blood pressure is 176/98 mm Hg.

Answer 26

B. The PaO2 level is at 46 mm Hg despite oxygen use.

Hypoxemia is a hallmark manifestation of ARDS. Refractory hypoxemia is when the patient is still hypoxic even though they are receiving a high level of oxygen (100% non-rebreather mask). The PaO2 at 46 mm HG despite O2 is low. Refractory hypoxemia is a PaO2 less than 50 mm HG with an FIO2 greater than 40%.

Question 27

Which intervention is most likely to prevent or limit barotrauma in the patient with acute respiratory distress syndrome (ARDS) who is mechanically ventilated?

A. Decreasing positive end-expiratory pressure (PEEP)

B. Use of permissive hypercapnia

C. Increasing the tidal volume

D. Use of positive-pressure ventilation

Answer 27

B. Use of permissive hypercapnia

When smaller tidal volumes and various amounts of PEEP are used, an elevation in PaCO2 called permissive hypercapnia occurs because the PaCO2 is allowed to rise above normal limits.

Question 28

With appropriate therapy, the overall goals for the patient with acute respiratory distress syndrome (ARDS) are a PaO2 of at least
——-?
mm Hg and adequate lung ventilation to maintain normal pH.

Answer 28

60

Question 29

Which intervention would the nurse anticipate for a patient with respiratory failure who has a respiratory rate of 6 breaths/min, an oxygen saturation (SpO2) of 88%, and is becoming increasingly lethargic?

A. Administration of 100% oxygen by non-rebreather mask

B. Insertion of a mini-tracheostomy with frequent suctioning

C. Endotracheal intubation and positive pressure ventilation

D. Initiation of continuous positive pressure ventilation (CPAP)

Answer 29

C. Endotracheal intubation and positive pressure ventilation

The patient’s lethargy, low respiratory rate, and SpO2 indicate the need for mechanical ventilation with ventilator-controlled respiratory rate.

Question 30

Which finding indicates the patient on mechanical ventilation with positive end-expiratory pressure (PEEP) is developing a complication related to their therapy and requires immediate treatment?

A. HCO3 at 25 mm Hg

B. Blood pressure at 72/46

C. PaO2 at 80 mm Hg

D. PaCO2 at 39 mm Hg

Answer 30

B. Blood pressure at 72/46

Mechanical ventilation with PEEP can cause issues with intrathoracic pressure and decrease the cardiac output (low blood pressure) along with hyperinflation of the lungs (possible pneumothorax or subcutaneous emphysema which is air that escapes into the skin because the lungs are leaking air).

Question 31

Which order would the nurse anticipate when caring for a patient with acute respiratory distress syndrome (ARDS) with a hemoglobin of 6.3 g/dL and an oxygen saturation of 90%?

A. Bolus of normal saline

B. Administration of furosemide

C. Administration of colloid solutions

D. Transfusion of packed red blood cells (RBCs)

Answer 31

D. Transfusion of packed red blood cells (RBCs)

The patient’s hemoglobin level is low, indicating the need for transfusion of packed RBCs.

Question 32

Which management strategy would a nurse expect as part of the plan of care for a patient with acute respiratory distress syndrome (ARDS)?

A. Use of positive end-expiratory pressure (PEEP)

B. Lateral recumbent patient positioning

C. Administration of a β-blocker

D. Aggressive use of IV fluids

Answer 32

A. Use of positive end-expiratory pressure (PEEP)

In ARDS, higher levels of PEEP may be used. It increases the functional residual capacity and opens collapsed alveoli.

Question 33

Which manifestation in a critically ill patient would the nurse suspect is the early stage of acute respiratory distress syndrome (ARDS)?

A. Respiratory acidosis

B. Diffuse crackles and rhonchi

C. Dyspnea and restlessness

D. Decreased PaO2 and an increased PaCO2

Answer 33

C. Dyspnea and restlessness

Early signs of ARDS are insidious and difficult to detect, but the nurse should be alert for any early signs of hypoxemia, such as dyspnea, restlessness, tachypnea, cough, and decreased mentation, in patients at risk for ARDS.

Question 34

Which intervention would the nurse initiate to prevent stress ulcers in a patient who has developed acute respiratory distress syndrome (ARDS) following multiple musculoskeletal injuries?

A. Observe stools for bleeding and occult blood.

B. Maintain head of the bed elevation at 30 to 45 degrees.

C. Begin enteral feedings as soon as bowel sounds are present.

D. Administer prescribed lorazepam (Ativan) to reduce anxiety.

Answer 34

C. Begin enteral feedings as soon as bowel sounds are present.

Stress ulcers prevention includes early initiation of enteral nutrition to protect the gastrointestinal (GI) tract from mucosal damage. Antiulcer agents such as histamine (H2)-receptor antagonists, proton pump inhibitors, and mucosal protecting agents are also indicated to prevent stress ulcers.

Question 35

Which nursing intervention is appropriate for a patient with acute respiratory distress syndrome (ARDS) with a functional saturation of oxygen (SpO2) of 93% who is in the prone position when the nurse starts their shift?

A. Initiate aspiration precautions.

B. Notify the health care provider.

C. Turn the patient to the supine position.

D. Continue to monitor per hospital protocol.

Answer 35

D. Continue to monitor per hospital protocol.

No action is needed if the patient is comfortable and vital signs/oxygen saturation are within normal limits. Some patients do better clinically when they are in the prone position. Oxygenation may be improved when patients are in the prone position than when they are in the supine position. Additionally, prone positioning could prevent ventilator-induced lung injury.

Question 36

Which medication is often used in a patient with acute respiratory distress syndrome (ARDS) who has had a decrease in their blood pressure that has affected their cardiac output?

A. Dopamine

B. Furosemide

C. Antibiotics

D. Epinephrine

Answer 36

A. Dopamine

Dopamine is an inotropic drug that can be used to increase cardiac output and blood pressure.