Deck 68: Nursing Management: Respiratory Failure and Acute Respiratory Distress Syndrome

Question 1

The nurse assesses that a patient in respiratory distress is developing respiratory fatigue and the risk of respiratory arrest when the patient displays which behavior?

A) Cannot breathe unless he is sitting upright
B) Uses the abdominal muscles during expiration
C) Has an increased inspiratory-expiratory (I/E) ratio
D) Has a change in respiratory rate from rapid to slow

Answer 1

D. The increase in respiratory rate required to blow off accumulated CO₂ predisposes to respiratory muscle fatigue. The slowing of a rapid rate in a patient in acute distress indicates tiring and the possibility of respiratory arrest unless ventilatory assistance is provided. A decreased inspiratory-expiratory (I/E) ratio, orthopnea, and accessory muscle use are common findings in respiratory distress but do not necessarily signal respiratory fatigue or arrest.

Question 2

The best patient response to treatment of ARDS occurs when initial management includes what?

A) Treatment of the underlying condition
B) Administration of prophylactic antibiotics
C) Treatment with diuretics and mild fluid restriction
D) Endotracheal intubation and mechanical ventilation

Answer 2

A. Because ARDS is precipitated by a physiologic insult, a critical factor in its prevention and early management is treatment of the underlying condition. Prophylactic antibiotics, treatment with diuretics and fluid restriction, and mechanical ventilation are also used as ARDS progresses.

Question 3

A patient has a PaO₂ of 50 mm Hg and a PaCO₂ of 42 mm Hg because of an intrapulmonary shunt.Which therapy is the patient most likely to respond best to?

A) Positive pressure ventilation
B) Oxygen administration at a FIO₂ of 100%
C) Administration of O₂ per nasal cannula at 1 to 3 L/min
D) Clearance of airway secretions with coughing and suctioning

Answer 3

A. Patients with a shunt are usually more hypoxemic than patients with a V/Q mismatch because the alveoli are filled with fluid, which prevents gas exchange. Hypoxemia resulting from an intrapulmonary shunt is usually not responsive to high O₂ concentrations and the patient will usually require positive pressure ventilation. Hypoxemia associated with a V/Q mismatch usually responds favorably to O₂ administration at 1 to 3 L/min by nasal cannula. Removal of secretions with coughing and suctioning is generally not effective in reversing an acute hypoxemia resulting from a shunt.

Question 4

When mechanical ventilation is used for the patient with ARDS, what is the rationale for applying positive end- expiratory pressure (PEEP)?

A) Prevent alveolar collapse and open up collapsed alveoli
B) Permit smaller tidal volumes with permissive hypercapnia
C) Promote complete emptying of the lungs during exhalation
D) Permit extracorporeal oxygenation and carbon dioxide removal outside the body

Question 5

A patient with a massive hemothorax and pneumothorax has absent breath sounds in the right lung.To promote improved V/Q matching, how should the nurse position the patient?

A) On the left side
B) On the right side
C) In a reclining chair bed
D) Supine with the head of the bed elevated

Question 6

The nurse suspects that a patient with PEEP is experiencing negative effects of this ventilatory maneuver when which of the following is assessed?

A) Increasing PaO₂
B) Decreasing blood pressure
C) Decreasing heart rate (HR)
D) Increasing central venous pressure (CVP)

Question 7

A patient in hypercapnic respiratory failure has a nursing diagnosis of ineffective airway clearance related to increasing exhaustion.What is an appropriate nursing intervention for this patient?

A) Inserting an oral airway
B) Performing augmented coughing
C) Teaching the patient huff coughing
D) Teaching the patient slow pursed lip breathing

Question 8

Prone positioning is considered for a patient with ARDS who has not responded to other measures to increase PaO₂.The nurse knows that this strategy will

A) increase the mobilization of pulmonary secretions.
B) decrease the workload of the diaphragm and intercostal muscles.
C) promote opening of atelectatic alveoli in the upper portion of the lung.
D) promote perfusion of nonatelectatic alveoli in the anterior portion of the lung.

Question 9

The patient with a history of heart failure and acute respiratory failure has thick secretions that she is having difficulty coughing up.Which intervention would best help to mobilize her secretions?

A) Administer more IV fluid
B) Perform postural drainage
C) Provide O₂ by aerosol mask
D) Suction airways nasopharyngeally

Question 10

Case study:
Acute Respiratory Failure
Patient Profile
P.C. is a 75-year-old married woman with severe oxygen- and corticosteroid-dependent chronic obstructive pulmonary
disease (COPD). She is admitted to the medical ICU in acute respiratory failure with pneumonia.
Subjective Data
• Complains of increasing shortness of breath and difficulty breathing with minimal exertion
Objective Data
• ABGs on 2 L O
2/min: pH 7.3, PaCO₂ 55 mm Hg, PaO₂ 60 mm Hg, SaO₂ 84%
• Awake, alert, and oriented
• Sitting in tripod position and using pursed lip breathing
Collaborative Care
• O
2 at 2 L/min per NIPPV
• Albuterol (Ventolin, Proventil) nebulization every hour PRN
• IV aminophylline
• IV antibiotics
• IV corticosteroids
What type of respiratory failure is P.C.primarily experiencing? Briefly describe how this situation illustrates the concept of acute chronic respiratory failure.

Question 11

Priority Decision: After endotracheal intubation and mechanical ventilation have been started, a patient in respiratory failure becomes very agitated and is breathing asynchronously with the ventilator.What is it most important for the nurse to do first?

A) Evaluate the patient's pain level, ABGs, and electrolyte values
B) Sedate the patient to unconsciousness to eliminate patient awareness
C) Administer the PRN vecuronium (Norcuron) to promote synchronous ventilations
D) Slow the rate of ventilations provided by the ventilator to allow for spontaneous breathing by the patient

Question 12

Case study:
Acute Respiratory Failure
Patient Profile
P.C. is a 75-year-old married woman with severe oxygen- and corticosteroid-dependent chronic obstructive pulmonary
disease (COPD). She is admitted to the medical ICU in acute respiratory failure with pneumonia.
Subjective Data
• Complains of increasing shortness of breath and difficulty breathing with minimal exertion
Objective Data
• ABGs on 2 L O
2/min: pH 7.3, PaCO₂ 55 mm Hg, PaO₂ 60 mm Hg, SaO₂ 84%
• Awake, alert, and oriented
• Sitting in tripod position and using pursed lip breathing
Collaborative Care
• O
2 at 2 L/min per NIPPV
• Albuterol (Ventolin, Proventil) nebulization every hour PRN
• IV aminophylline
• IV antibiotics
• IV corticosteroids
What factors contributed to the development of respiratory failure in P.C.?

Question 13

When explaining respiratory failure to the patient's family, what should the nurse use as an accurate description?

A) The absence of ventilation
B) Any episode in which part of the airway is obstructed
C) Inadequate gas exchange to meet the metabolic needs of the body
D) An episode of acute hypoxemia caused by a pulmonary dysfunction

Question 14

What is the primary reason that hemodynamic monitoring is instituted in severe respiratory failure?

A) To detect V/Q mismatches
B) To continuously measure the arterial BP
C) To evaluate oxygenation and ventilation status
D) To evaluate cardiac status and blood flow to tissues

Question 15

Case study:
Acute Respiratory Failure
Patient Profile
P.C. is a 75-year-old married woman with severe oxygen- and corticosteroid-dependent chronic obstructive pulmonary
disease (COPD). She is admitted to the medical ICU in acute respiratory failure with pneumonia.
Subjective Data
• Complains of increasing shortness of breath and difficulty breathing with minimal exertion
Objective Data
• ABGs on 2 L O
2/min: pH 7.3, PaCO₂ 55 mm Hg, PaO₂ 60 mm Hg, SaO₂ 84%
• Awake, alert, and oriented
• Sitting in tripod position and using pursed lip breathing
Collaborative Care
• O
2 at 2 L/min per NIPPV
• Albuterol (Ventolin, Proventil) nebulization every hour PRN
• IV aminophylline
• IV antibiotics
• IV corticosteroids
What are the pathophysiologic effects and clinical manifestations of P.C.'s respiratory failure?

Question 16

Which descriptions are characteristic of hypoxemic respiratory failure (select all that apply)?

A) Referred to as ventilatory failure
B) Primary problem is inadequate O₂ transfer
C) Risk of inadequate O₂ saturation of hemoglobin exists
D) Body is unable to compensate for acidemia of increased PaCO₂
E) Most often caused by ventilation-perfusion (V/Q) mismatch and shunt
F) Exists when PaO₂ is 60 mm Hg or less, even when O₂ is administered at 60%

Question 17

Patients with acute respiratory failure will have drug therapy to meet their individual needs.Which drugs will meet the goal of reducing pulmonary congestion (select all that apply)?

A) Morphine
B) Furosemide (Lasix)
C) Nitroglycerin (Tridil)
D) Albuterol (Ventolin)
E) Ceftriaxone (Rocephin)
F) Methylprednisolone (Solu-Medrol)

Question 18

Case study:
Acute Respiratory Failure
Patient Profile
P.C. is a 75-year-old married woman with severe oxygen- and corticosteroid-dependent chronic obstructive pulmonary
disease (COPD). She is admitted to the medical ICU in acute respiratory failure with pneumonia.
Subjective Data
• Complains of increasing shortness of breath and difficulty breathing with minimal exertion
Objective Data
• ABGs on 2 L O
2/min: pH 7.3, PaCO₂ 55 mm Hg, PaO₂ 60 mm Hg, SaO₂ 84%
• Awake, alert, and oriented
• Sitting in tripod position and using pursed lip breathing
Collaborative Care
• O
2 at 2 L/min per NIPPV
• Albuterol (Ventolin, Proventil) nebulization every hour PRN
• IV aminophylline
• IV antibiotics
• IV corticosteroids
How do the tripod position and pursed lip breathing contribute to respiratory function?

Question 19

When teaching the patient about what was happening when experiencing an intrapulmonary shunt, which explanation is accurate?

A) This occurs when an obstruction impairs the flow of blood to the ventilated areas of the lung.
B) This occurs when blood passes through an anatomic channel in the heart and bypasses the lungs.
C) This occurs when blood flows through the capillaries in the lungs without participating in gas exchange.
D) Gas exchange across the alveolar capillary interface is compromised by thickened or damaged alveolar membranes.

Question 20

In caring for a patient in acute respiratory failure, the nurse recognizes that noninvasive positive pressure ventilation (NIPPV) may be indicated for which patient?

A) Is comatose and has high oxygen requirements
B) Has copious secretions that require frequent suctioning
C) Responds to hourly bronchodilator nebulization treatments
D) Is alert and cooperative but has increasing respiratory exhaustion

Question 21

Case study:
Acute Respiratory Failure
Patient Profile
P.C. is a 75-year-old married woman with severe oxygen- and corticosteroid-dependent chronic obstructive pulmonary
disease (COPD). She is admitted to the medical ICU in acute respiratory failure with pneumonia.
Subjective Data
• Complains of increasing shortness of breath and difficulty breathing with minimal exertion
Objective Data
• ABGs on 2 L O
2/min: pH 7.3, PaCO₂ 55 mm Hg, PaO₂ 60 mm Hg, SaO₂ 84%
• Awake, alert, and oriented
• Sitting in tripod position and using pursed lip breathing
Collaborative Care
• O
2 at 2 L/min per NIPPV
• Albuterol (Ventolin, Proventil) nebulization every hour PRN
• IV aminophylline
• IV antibiotics
• IV corticosteroids
What is NIPPV? When is it contraindicated?

Question 22

When the V/Q lung scan result returns with a mismatch ratio that is greater than 1, which condition should be suspected?

A) Pain
B) Atelectasis
C) Pulmonary embolus
D) Ventricular septal defect

Question 23

The patient progressed from acute lung injury to acute respiratory distress syndrome (ARDS).He is on the ventilator and receiving propofol (Diprivan) for sedation and fentanyl (Sublimaze) to decrease anxiety, agitation, and pain in order to decrease his work of breathing, O₂ consumption, carbon dioxide production, and risk of injury.What intervention is recommended in caring for this patient?

A) A sedation holiday
B) Monitoring for hypermetabolism
C) Keeping his legs still to avoid dislodging the airway
D) Repositioning him every 4 hours to decrease agitation

Question 24

Case study:
Acute Respiratory Failure
Patient Profile
P.C. is a 75-year-old married woman with severe oxygen- and corticosteroid-dependent chronic obstructive pulmonary
disease (COPD). She is admitted to the medical ICU in acute respiratory failure with pneumonia.
Subjective Data
• Complains of increasing shortness of breath and difficulty breathing with minimal exertion
Objective Data
• ABGs on 2 L O
2/min: pH 7.3, PaCO₂ 55 mm Hg, PaO₂ 60 mm Hg, SaO₂ 84%
• Awake, alert, and oriented
• Sitting in tripod position and using pursed lip breathing
Collaborative Care
• O
2 at 2 L/min per NIPPV
• Albuterol (Ventolin, Proventil) nebulization every hour PRN
• IV aminophylline
• IV antibiotics
• IV corticosteroids
What other nursing interventions will assist P.C.in recovery?

Question 25

Which physiologic mechanism of hypoxemia occurs with pulmonary fibrosis?

A) Anatomic shunt
B) Diffusion limitation
C) Intrapulmonary shunt
D) V/Q mismatch ratio of less than 1

Question 26

Although ARDS may result from direct lung injury or indirect lung injury as a result of systemic inflammatory response syndrome (SIRS), the nurse is aware that ARDS is most likely to occur in the patient with a host insult resulting from

A) sepsis.
B) oxygen toxicity.
C) prolonged hypotension.
D) cardiopulmonary bypass.

Question 27

Case study:
Acute Respiratory Failure
Patient Profile
P.C. is a 75-year-old married woman with severe oxygen- and corticosteroid-dependent chronic obstructive pulmonary
disease (COPD). She is admitted to the medical ICU in acute respiratory failure with pneumonia.
Subjective Data
• Complains of increasing shortness of breath and difficulty breathing with minimal exertion
Objective Data
• ABGs on 2 L O
2/min: pH 7.3, PaCO₂ 55 mm Hg, PaO₂ 60 mm Hg, SaO₂ 84%
• Awake, alert, and oriented
• Sitting in tripod position and using pursed lip breathing
Collaborative Care
• O
2 at 2 L/min per NIPPV
• Albuterol (Ventolin, Proventil) nebulization every hour PRN
• IV aminophylline
• IV antibiotics
• IV corticosteroids
Priority Decision: Which of the treatments instituted for P.C.is the most important in returning her to her usual level of respiratory function?

Question 28

Which patient with the following manifestations is most likely to develop hypercapnic respiratory failure?

A) Rapid, deep respirations in response to pneumonia
B) Slow, shallow respirations as a result of sedative overdose
C) Large airway resistance as a result of severe bronchospasm
D) Poorly ventilated areas of the lung caused by pulmonary edema

Question 29

What are the primary pathophysiologic changes that occur in the injury or exudative phase of ARDS (select all that apply)?

A) Atelectasis
B) Shortness of breath
C) Interstitial and alveolar edema
D) Hyaline membranes line the alveoli
E) Influx of neutrophils, monocytes, and lymphocytes

Question 30

Case study:
Acute Respiratory Failure
Patient Profile
P.C. is a 75-year-old married woman with severe oxygen- and corticosteroid-dependent chronic obstructive pulmonary
disease (COPD). She is admitted to the medical ICU in acute respiratory failure with pneumonia.
Subjective Data
• Complains of increasing shortness of breath and difficulty breathing with minimal exertion
Objective Data
• ABGs on 2 L O
2/min: pH 7.3, PaCO₂ 55 mm Hg, PaO₂ 60 mm Hg, SaO₂ 84%
• Awake, alert, and oriented
• Sitting in tripod position and using pursed lip breathing
Collaborative Care
• O
2 at 2 L/min per NIPPV
• Albuterol (Ventolin, Proventil) nebulization every hour PRN
• IV aminophylline
• IV antibiotics
• IV corticosteroids
What discharge teaching should be started?

Question 31

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

A) PaO₂ 52 mm Hg, PaCO₂ 56 mm Hg, pH 7.4
B) PaO₂ 46 mm Hg, PaCO₂ 52 mm Hg, pH 7.36
C) PaO₂ 48 mm Hg, PaCO₂ 54 mm Hg, pH 7.38
D) PaO₂ 50 mm Hg, PaCO₂ 54 mm Hg, pH 7.28

Question 32

In patients with ARDS who survive the acute phase of lung injury, what manifestations are seen when they progress to the fibrotic phase?

A) Chronic pulmonary edema and atelectasis
B) Resolution of edema and healing of lung tissue
C) Continued hypoxemia because of diffusion limitation
D) Increased lung compliance caused by the breakdown of fibrotic tissue

Question 33

Case study:
Acute Respiratory Failure
Patient Profile
P.C. is a 75-year-old married woman with severe oxygen- and corticosteroid-dependent chronic obstructive pulmonary
disease (COPD). She is admitted to the medical ICU in acute respiratory failure with pneumonia.
Subjective Data
• Complains of increasing shortness of breath and difficulty breathing with minimal exertion
Objective Data
• ABGs on 2 L O
2/min: pH 7.3, PaCO₂ 55 mm Hg, PaO₂ 60 mm Hg, SaO₂ 84%
• Awake, alert, and oriented
• Sitting in tripod position and using pursed lip breathing
Collaborative Care
• O
2 at 2 L/min per NIPPV
• Albuterol (Ventolin, Proventil) nebulization every hour PRN
• IV aminophylline
• IV antibiotics
• IV corticosteroids
Priority Decision: Based on the assessment data presented, what are the priority nursing diagnoses? Are there any collaborative problems?

Question 34

The patient is being admitted to the intensive care unit (ICU) with hypercapnic respiratory failure.Which manifestations should the nurse expect to assess in the patient (select all that apply)?

A) Cyanosis
B) Metabolic acidosis
D) Respiratory acidosis
E) Use of tripod position

Question 35

In caring for the patient with ARDS, what is the most characteristic sign the nurse would expect the patient to exhibit?

A) Refractory hypoxemia
B) Bronchial breath sounds
C) Progressive hypercapnia
D) Increased pulmonary artery wedge pressure (PAWP)

Question 36

Which assessment finding should cause the nurse to suspect the early onset of hypoxemia?

A) Restlessness
B) Hypotension
C) Central cyanosis
D) Cardiac dysrhythmias

Question 37

The nurse suspects the early stage of ARDS in any seriously ill patient who manifests what?

A) Develops respiratory acidosis
B) Has diffuse crackles and rhonchi
C) Exhibits dyspnea and restlessness
D) Has a decreased PaO₂ and an increased PaCO₂

Question 38

Which changes of aging contribute to the increased risk for respiratory failure in older adults (select all that apply)?

A) Alveolar dilation
B) Increased delirium
C) Changes in vital signs
D) Increased infection risk
E) Decreased respiratory muscle strength
F) Diminished elastic recoil within the airways

Question 39

A patient with ARDS has a nursing diagnosis of risk for infection.To detect the presence of infections commonly associated with ARDS, what should the nurse monitor?

A) Gastric aspirate for pH and blood
B) Quality, quantity, and consistency of sputum
C) Subcutaneous emphysema of the face, neck, and chest
D) Mucous membranes of the oral cavity for open lesions