TB Ch 67 ARF and ARDS

Question 1

1. To evaluate the effectiveness of ordered interventions for a patient with ventilatory failure, which diagnostic
   test will be most useful to the nurse?

Answer 1

c. Arterial blood gas analysis

Question 2

2. While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in
   the patients oxygen saturation (SpO2) from 94% to 88%. Which action should the nurse take next?

Answer 2

Increase the oxygen flow rate.

Question 3

3. A patient with respiratory failure has a respiratory rate of 6 breaths/minute and an oxygen saturation (SpO2)of 88%. The patient is increasingly lethargic. Which intervention will the nurse anticipate?

Answer 3

b. Endotracheal intubation and positive pressure ventilation

Question 4

4. The oxygen saturation (SpO2) for a patient with left lower lobe pneumonia is 90%. The patient has rhonchi,
   a weak cough effort, and complains of fatigue. Which action is a priority for the nurse to take?

Answer 4

b. Assist the patient with staged coughing.

Question 5

5. A nurse is caring for an obese patient with right lower lobe pneumonia. Which position will be best to
   improve gas exchange?

Answer 5

a. On the left side

Question 6

6. When admitting a patient with possible respiratory failure with a high PaCO2, which assessment information
   should be immediately reported to the health care provider?

Answer 6

a. The patient is somnolent.

Question 7

7. A patient with acute respiratory distress syndrome (ARDS) and acute kidney injury has the following
   medications ordered. Which medication should the nurse discuss with the health care provider before giving?

Answer 7

b. Gentamicin (Garamycin) 60 mg IV

Question 8

8. A patient develops increasing dyspnea and hypoxemia 2 days after heart surgery. To determine whether the
   patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by heart failure, the nurse
   will plan to assist with

Answer 8

c. insertion of a pulmonary artery catheter.

Question 9

9. A nurse is caring for a patient with ARDS who is being treated with mechanical ventilation and high levels
   of positive end-expiratory pressure (PEEP). Which assessment finding by the nurse indicates that the PEEP
   may need to be reduced?

Answer 9

. The patient has subcutaneous emphysema on the upper thorax.

Question 10

10. Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to
    the family members of a patient with ARDS is accurate?

Answer 10

b. PEEP prevents the lung air sacs from collapsing during exhalation.

Question 11

11. A patient with acute respiratory distress syndrome (ARDS) is placed in the prone position. When prone
    positioning is used, which information obtained by the nurse indicates that the positioning is effective?

Answer 11

a. The patients PaO2 is 89 mm Hg, and the SaO2 is 91%.

Question 12

12. The nurse documents the vital signs for a patient admitted 2 days ago with gram-negative sepsis:
    temperature 101.2 F, blood pressure 90/56 mm Hg, pulse 92, respirations 34. Which action should the nurse
    take next?

Answer 12

c. Obtain oxygen saturation using pulse oximetry.

Question 13

13. 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?

Answer 13

a. Elevate head of bed to 30 to 45 degrees.

Question 14

14. A patient admitted with acute respiratory failure has a nursing diagnosis of ineffective airway clearance
    related to thick, secretions. Which action is a priority for the nurse to include in the plan of care?

Answer 14

b. Offer the patient fluids at frequent intervals.

Question 15

15. A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical
    ventilation develops a right pneumothorax. Which action will the nurse anticipate taking next?

Answer 15

d. Lower the positive end-expiratory pressure (PEEP).

Question 16

16. After receiving change-of-shift report on a medical unit, which patient should the nurse assess first?

Answer 16

d. A patient with septicemia who has intercostal and suprasternal retractions

Question 17

17. A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department
    complaining of shortness of breath and dyspnea on minimal exertion. Which assessment finding by the nurse is
    most important to report to the health care provider?

Answer 17

d. The patient’s pulse oximetry indicates an O2 saturation of 91%.

Question 18

18. When assessing a patient with chronic obstructive pulmonary disease (COPD), the nurse finds a new-onset
    of agitation and confusion. Which action should the nurse take first?

Answer 18

d. Assess oxygenation using pulse oximetry.

Question 19

19. The nurse is caring for a 33-year-old patient who arrived in the emergency department with acute
    respiratory distress. Which assessment finding by the nurse requires the most rapid action?

Answer 19

a. The patient’s PaO2 is 45 mm Hg.

Question 20

20. The nurse is caring for a 78-year-old patient who was hospitalized 2 days earlier with community-acquired
    pneumonia. Which assessment information is most important to communicate to the health care provider?

Answer 20

d. Decreased oxygen saturation to 90% with 100% O2 by the non-rebreather mask.

Question 21

21. Which nursing interventions included in the care of a mechanically ventilated patient with acute respiratory failure can the registered nurse (RN) delegate to an experienced licensed practical/vocational nurse
    (LPN/LVN) working in the intensive care unit?

Answer 21

d. Insert an indwelling urinary catheter.

Question 22

22. A nurse is caring for a patient with acute respiratory distress syndrome (ARDS) who is receiving
    mechanical ventilation using synchronized intermittent mandatory ventilation (SIMV). The settings include
    fraction of inspired oxygen (FIO2) 80%, tidal volume 450, rate 16/minute, and positive end-expiratory pressure
    (PEEP) 5 cm. Which assessment finding is most important for the nurse to report to the health care provider?

Answer 22

a. Oxygen saturation 99%

Question 23

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

Answer 23

a. Only continuous IV opioids have been ordered.

Question 24

24. The nurse is caring for a patient who is intubated and receiving positive pressure ventilation to treat acute
    respiratory distress syndrome (ARDS). Which finding is most important to report to the health care provider?

Answer 24

b. Red-brown drainage from orogastric tube

Question 25

25. 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 should the nurse
    take first?

Answer 25

c. Use pulse oximetry to check the oxygen saturation.

Question 26

1. Which actions should the nurse initiate to reduce the risk for ventilator-associated pneumonia (VAP) (select
   all that apply)?

Answer 26

b. Provide a sedation holiday daily.
c. Elevate the head of the bed to at least 30.
d. Give prescribed pantoprazole (Protonix).
e. Provide oral care with chlorhexidine (0.12%) solution daily.