NCLEX Style Prep for Midterm

Question 1

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.
2. You’re teaching a class on critical care

Answer 1

The answer is C. 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.

Question 2

You’re teaching a class on critical care concepts to a group of new nurses. You’re discussing the topic of acute respiratory distress syndrome (ARDS). At the beginning of the lecture, you assess the new nurses understanding about this condition. Which statement by a new nurse demonstrates he understands the condition?

A. “This condition develops because the exocrine glands start to work incorrectly leading to thick, copious mucous to collect in the alveoli sacs.”
B. “ARDS is a pulmonary disease that gradually causes chronic obstruction of airflow from the lungs.”
C. “Acute respiratory distress syndrome occurs due to the collapsing of a lung because air has accumulated in the pleural space.”
D. “This condition develops because alveolar capillary membrane permeability has changed leading to fluid collecting in the alveoli sacs.”

Answer 2

The answer is D. ARDS is a type of respiratory failure that occurs when the capillary membrane that surrounds the alveoli sac becomes damaged, which causes fluid to leak into the alveoli sac. Option A describes cystic fibrosis, option B describes COPD, and option C describes a pneumothorax.

Question 3

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

Answer 3

The answer is B. 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 ATELECTASIS will occur (collapse of the lung tissue) when there is a decrease production in surfactant.

Question 4

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

Answer 4

The answer is C. This is a finding found in ARDS….pronounce white-out infiltrates bilaterally.

Question 5

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

Answer 5

The answer is A. 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.

Question 6

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.

Answer 6

The answer is C. 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.

Question 7

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

Answer 7

The answers are: C, D, F 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).

Question 8

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

Answer 8

The answer is B. 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).

Question 9

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

Answer 9

The answers are A and C. 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.

Question 10

A patient is experiencing respiratory failure due to pulmonary edema. The physician suspects ARDS but wants to rule out a cardiac cause. A pulmonary artery wedge pressure is obtained. As the nurse you know that what measurement reading obtained indicates that this type of respiratory failure is NOT cardiac related?

A. >25 mmHg
B. <10 mmHg
C. >50 mmHg
D. <18 mmHg

Answer 10

The answer is D. 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 but most likely ARDS. Therefore, the pulmonary edema is due to damage to the alveolar capillary membrane leaking fluid into the alveolar sac….NOT a heart problem ex: heart failure.

Question 11

You’re precepting a nursing student who is assisting you care for a patient on mechanical ventilation with PEEP for treatment of ARDS. The student asks you why the PEEP setting is at 10 mmHg. Your response is:

A. “This pressure setting assists the patient with breathing in and out and helps improve air flow.”
B. “This pressure setting will help prevent a decrease in cardiac output and hyperinflation of the lungs.”
C. “This pressure setting helps prevent fluid from filling the alveoli sacs.”
D. “This pressure setting helps open the alveoli sacs that are collapsed during exhalation.”

Answer 11

The answer is D. This setting of PEEP (it can range between 10 to 20 mmHg of water) and it helps to open the alveoli sacs that are collapsed, especially during exhalation.

Question 12

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. Decreased pleural pressure
C. Reduced need for endotracheal intubation
D. Increased response to corticosteroid therapy
E. Mobilization of secretions

Answer 12

A, B, E

• “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.
• “Reduced need for endotracheal intubation” is incorrect. The prone position has not been shown to decrease the likelihood of intubation.
• “Increased response to corticosteroid therapy” is incorrect because positioning does not change the body’s response to steroid therapy.

Question 13

A nurse is caring for a client 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. A respiratory rate greater than 16 breaths per minute
D. A pCO2 level over 50 mmHg
E. An ABG pH level of 7.35

Answer 13

B and E

“A PaO2 level below 60 mmHg” and “A pCO2 level over 50 mmHg” are correct. Respiratory failure occurs when the body cannot remove enough carbon dioxide, and/or cannot take in enough oxygen to be sustainable. Clinical indicators of respiratory failure include pulse oximetry of less than 90% on room air, PaO2 level less than 60 mmHg, and a pCO2 level of over 50 mmHg.

“Pulse oximetry of 94% on room air” is incorrect. 94% is a normal pulse oximetry reading.

“An ABG pH level of 7.35” is incorrect, because this pH level is normal.

“A respiratory rate greater than 16 breaths per minute” is incorrect, because a respiratory rate over 16 is within the normal range.

Question 14

A nurse is caring for a patient who is in respiratory distress because of ARDS. Which of the following nursing diagnoses would most likely be associated with this condition?

A. Ineffective tissue perfusion
B. Ineffective thermoregulation
C. Impaired urinary elimination
D. Disturbed personal identity

Answer 14

A

Acute respiratory distress syndrome (ARDS) is a life-threatening condition that affects the lungs and prevents the patient from getting enough oxygen. The patient in this situation would most likely have a nursing diagnosis of ineffective tissue perfusion, as decreased oxygen from lung disease prevents adequate oxygen from reaching the bloodstream and the peripheral tissues.

Question 15

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 more oxygen because of his saturations
B. The patient needs endotracheal suctioning
C. The patient needs a hemoglobin level drawn
D. The patient needs an arterial blood gas drawn

Answer 15

D

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.

Question 16

A nurse is caring for a client with ARDS and views the ABG results seen in the diagram. Based on the ABG results, which of the following findings would the nurse be most likely find in this client?

ABG Results:

pH of 7.35
PaCO2 of 24 mmHg
HCO3 of 22 mmHg
PaO2 of 95

A. RR 32 bpm
B. HR 94 bpm
C. SpO2 82%
D. BP 124/68 mmHg

Answer 16

A

“RR 32 bpm” is correct. The normal range for PaCO2 is 35-45. Hyperventilation (increased respiratory rate) can cause the PaCO2 level to drop, leading to respiratory alkalosis. This client has compensated by decreasing the bicarb level, but this finding should still be reported to the provider so that appropriate interventions can be ordered.

“SpO2 82%” is incorrect. The client has a PaO2 of 95 mmHg. Although it is possible, it is unlikely that this client has such a low SpO2. There is another value in these results that is more significant and has a possible direct cause. Therefore, this is not the most likely finding.

“HR 94 bpm” and “BP 124/68 mmHg” are incorrect as they are both normal and neither of these would relate to the ABG findings.

Question 17

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. Insulin resistance
B. Seizures
C. Impaired mental status
D. Constipation
E. Persistent weight loss

Answer 17

A, B, C

• “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.
• “Persistent weight loss” is incorrect because by the time a patient develops re-feeding syndrome, the onset of symptoms is so sudden that weight loss cannot be measured as part of the syndrome.
• “Constipation” is incorrect, as it is not a symptom of refeeding syndrome.