Deck 3: Care of the Patient With Respiratory Failure

Question 1

The nurse explains the purpose of a tracheostomy tube for mechanical ventilation. Which patient statement indicates the need for additional teaching?
1) "It is used for long-term management, usually more than 2 or 3 weeks."
2) "It allows the respiratory muscles to be strengthened by increasing resistance to airflow."
3) "It is easier to use when there are increased secretions that need to be removed by suctioning."
4) "It is a method that allows oral nutrition to be resumed."

Answer 1

2
Explanation: 1. This statement would not indicate the need for additional teaching.
2. The tracheostomy reduces dead space, allowing the flow of air more easily into the airways, so there is a decreased resistance to airflow. This statement indicates that additional teaching is needed.
3. This statement would not indicate the need for additional teaching.
4. This statement would not indicate the need for additional teaching.

Question 2

Which setting on a ventilator would require a nursing intervention to improve the outcome for a 60-kg patient with acute lung injury (ALI)?
1) FiO₂ = 0.30 or 30%
2) Tidal volume (V_T) = 900 mL
3) Respiratory rate = 15 per minute, when the CO₂ levels are elevated
4) Inspiratory:Expiratory ratio (I:E) = 1:2

Answer 2

2
Explanation: 1. The patient with ALI needs supplemental oxygen to help maintain PaO₂.
2. V_T is the volume of gas delivered in one ventilatory cycle. VT is normally 7 mL/kg of body weight or around 500 mL. In mechanical ventilation, the volume is kept at 5-8 mL/kg in order to prevent trauma to lung tissues. In ALI, lower volumes are preferred. The nurse would need to discuss reducing the tidal volume with members of the multidisciplinary team.
3. No action is needed by the nurse. The rate is increased to allow the blow off of CO₂; therefore, a rate of 15 per minute is adequate for the patient with ALI.
4. It would not benefit the patient to alter the I:E ratio while the tidal volume for this patient is excessive.

Question 3

Arterial blood gas (ABG) results of an intubated, mechanically ventilated patient are as follows: pH 7.33; PaO₂ 50; PaCO 49; bicarbonate 27. What nursing action is a priority for this patient?
1) Increase respiratory rate and FiO₂.
2) Increase IV fluids.
3) Add positive end expiratory pressure.
4) Decrease the respiratory rate and FiO₂.

Answer 3

1
Explanation: 1. This patient is in respiratory acidosis due to inadequate ventilation. The correct action would be to increase rate and FiO₂.
2. Administering IV fluids would not be appropriate because this would interfere with oxygenation.
3. Positive end expiratory pressure is usually prescribed during the weaning process. This patient is not being weaned from the ventilator.
4. This would not improve the patient's ABG or respiratory status.

Question 4

What should the nurse expect to assess in a patient experiencing the fibrotic phase of acute lung injury?
1) Pulmonary occlusive pressures less than 18 mm Hg
2) Bilateral fluid seen on radiographic exams
3) Severe bleeding from all body orifices
4) Fever and leukocytosis

Question 5

What should the nurse expect to assess in a patient with respiratory failure and hypoxemia?
1) Exertional dyspnea, circumoral cyanosis, distal cyanosis
2) Subcutaneous emphysema, absent breath sounds, sharp chest pain
3) Agitation, disorientation, lethargy, chest pain
4) Rales, distended neck veins, orthostatic hypotension

Question 6

Which arterial blood gas result indicates the development of an acute lung injury?
1) pH 7.4, PaCO₂ 40 mm Hg, PaO₂ 96, HCO₃ 24 mEq, SaO₂ 94%
2) pH 7.31, PaCO₂ 50 mm Hg, PaO₂ 70 mm Hg, HCO₃ 20 mEq, SaO₂ 90%
3) pH 7.49, PaCO₂ 32 mm Hg, PaO₂ 75 mm Hg, HCO₃ 22 mEq, SaO₂ 90%
4) pH 7.29, PCO₂ 28 mm Hg, PaO₂ 97 mm Hg, HCO₃, 16 mEq, SaO₂ 94%

Question 7

A patient is diagnosed with type I hypoxemic failure. The nurse should realize that this type of respiratory failure is linked to what?
1) Muscular failure to move the air into and out of the lungs
2) Failure of the neurological system to stimulate respirations
3) Skeletal alterations of the thoracic region that limit air movement
4) Breakdown of oxygen transport from the alveolus to arterial flow

Question 8

The nurse receives the following ABG result: pH = 7.00
PaCO₂ = 50 mm Hg
PaO₂ = 89 mm Hg
SaO₂ = 90%
Based on the results, what should the nurse do first?
1) Check the last dose of CNS depressant drug.
2) Assess lung sounds and vital signs.
3) Review the history for asthma or emphysema.
4) Apply oxygen per nasal cannula at 2 L/min.

Question 9

Which patients should the nurse identify as being at risk for developing type II hypoxemic hypercapneic failure? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) A 5-year-old male with a 5-year history of muscular dystrophy
2) A 34-year-old female patient who is 3 days' postoperative open cholecystectomy
3) A 24-year-old male newly admitted with possible Guillain-Barré syndrome
4) A 72-year-old female with kyphosis
5) An 85-year-old patient admitted with aspiration pneumonia

Question 10

When assessing a patient with type I hypoxemic failure, the nurse should evaluate for which contributing health problem? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Acute respiratory distress syndrome
2) Asthma
3) Cardiogenic pulmonary edema
4) Pneumonia
5) Narcotic overdose

Question 11

When caring for a patient with damage to the cerebral cortex, which change in respiration and ventilation should the nurse expect to observe?
1) Increased rate of breathing per minute
2) Increased respiratory effort by the use of chest and diaphragm muscles
3) Decreased voluntary initiation of ventilatory effort
4) Decrease in CO₂ in blood analysis

Question 12

The nurse instructs a patient on the advantages of noninvasive mechanical ventilation (NIV). Which patient statement reflects a need for additional teaching?
1) "I will not have to have a tube down my throat for it to work."
2) "I will probably recover faster, so I can get out of the hospital faster."
3) "I am more likely to have fewer complications such as pneumonia."
4) "Noninvasive ventilation is not uncomfortable, and I won't have to be admitted to ICU to use it."

Question 13

When planning care for a patient who is mechanically ventilated, the nurse should include interventions to address which potential complications? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Cardiovascular compromise
2) Community acquired pneumonia (CAP)
3) Barotrauma
4) Volutrauma
5) Anxiety from lack of synchrony with the ventilator

Question 14

Which statement made by a new graduate nurse about invasive mechanical ventilation techniques is incorrect and requires additional teaching?
1) "Assist control mode refers to the patient receiving a set total lung capacity (TLC), but the rate can be modified by the patient's own rate of breathing."
2) "Total control mode controls both the rate and volume that are preset and delivered without the machine responding to any of the patient's own breaths."
3) "Synchronized intermittent mandatory ventilation (SIMV) refers to the patient setting an independent rate but limited tidal volume based on the patient's own strength. A minimum rate is also used as a backup to prevent hypoventilation."
4) "Continuous positive airway pressure will increase the residual capacity and keep the alveoli open. Rate and volume are controlled by the patient. This is one step in the weaning process."

Question 15

Which patient should the nurse identify as benefiting from the use of noninvasive ventilation (NIV)?
1) A 55-year-old female with an acute exacerbation of asthma
2) A 57-year-old male with a history of sleep apnea
3) A 48-year-old female with an acute myocardial infarction
4) A 72-year-old male with sepsis

Question 16

The nurse searches the health history of a patient diagnosed with an acute lung injury for a reason for the disease process. Which statement correctly identifies the cause for this type of lung injury?
1) Acute lung injury can be caused indirectly from sepsis, systemic inflammatory response syndrome, or pancreatitis.
2) Acute lung injury is a single organ dysfunction syndrome that has a chronic onset.
3) Acute lung injury is caused by few infiltrates on chest radiography.
4) Acute lung injury is caused by right ventricular failure.

Question 17

The nurse is suctioning an intubated, mechanically ventilated patient. For which complication should the nurse assess this client?
1) Dysrhythmias
2) Hyperthermia
3) Hematuria
4) Decreased urinary output

Question 18

Which nursing action optimizes overall oxygenation and ventilation in the patient with acute respiratory distress syndrome (ARDS)?
1) Provide adequate rest and recovery time between procedures.
2) Hyperventilate the patient before and after suctioning.
3) Administer sedation frequently.
4) Suction the patient as needed.

Question 19

Which assessment findings should indicate to the nurse that a patient is experiencing respiratory distress? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Tachycardia
2) Use of abdominal muscles
3) Intercostal muscle retractions
4) Bradypnea
5) Jugular vein distention

Question 20

A patient with ARDS is on a mechanical ventilator and is becoming increasingly restless with a heart rate of 128 bpm. The SaO₂ is 88% and the ventilator settings are FiO₂ 50%; PEEP 8 cm; AC 10 with a total respiratory rate of 30; and a tidal volume of 700 mL. There are coarse rhonchi audible in all lung fields. Which action should the nurse take?
1) Hyperoxygenate with 100% oxygen and suction the patient.
2) Administer the ordered neuromuscular blockade medications.
3) Increase the FiO₂ to 60% and tidal volume to 750 mL for 2 minutes.
4) Increase the PEEP to 10 cm and sedate the patient.

Question 21

A patient with an acute lung injury has lower extremity edema. What should the nurse expect to be prescribed to treat this patient's problem?
1) Fluid restriction
2) Colloid infusions
3) Low-dose furosemide
4) 0.9% normal saline infusion

Question 22

The nurse assesses an older patient's respiratory status. Which finding should the nurse identify as being an expected age-related change? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Weak cough
2) Nasal flaring
3) Shortness of breath
4) Increased AP diameter
5) Copious mucous production

Question 23

During multidisciplinary rounds, a discussion is held regarding the use of medications in acute respiratory distress syndrome (ARDS). Which statement is most accurate based upon published research findings?
1) Corticosteroids are used for their anti-inflammatory property to manage the cytokine-mediated inflammatory response in ARDS.
2) Exogenous surfactant therapy is more beneficial to adult patients with ARDS than when it is given to neonates.
3) β-agonists reduce pulmonary edema and inflammation.
4) Inhaled nitric oxide promotes blood flow to ventilated areas of the lungs.

Question 24

What assessment finding indicates that a patient is in the fibroproliferative phase of acute respiratory distress syndrome? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Crackles on auscultation
2) Agitation
3) Peripheral edema
4) Fever
5) Increased heart rate and drop in blood pressure

Question 25

A patient with chronic obstructive pulmonary disease (COPD) experiences shortness of breath. What should the nurse explain to the patient about this symptom?
1) "It is because you have excess fluid in your lungs."
2) "It is caused by excess mucus in your lung membranes."
3) "It's because you have excess carbon dioxide trapped in your lungs."
4) "It is because you have pneumonia that has not been treated correctly."

Question 26

A patient with acute respiratory distress syndrome is being mechanically ventilated. What actions should the nurse take to prevent ventilator-induced injury? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Keep the tidal volume between 5 and 8 mL/kg.
2) Keep the plateau pressure ≤ 30 cm H₂O.
3) Keep FiO₂ ≤ 60%.
4) Assess arterial blood gas values for a PaCO₂ to be between 60 and 100.
5) Set PEEP at 5-15 cm H₂O.

Question 27

A patient is annoyed by a cough that occurs at change of seasons. What should the nurse explain to the patient about this symptom?
1) "A cough is harmful and should be suppressed."
2) "A cough is a protective reflex to clear debris out of the lungs."
3) "A cough means that you are fighting an upper respiratory infection."
4) "A cough propels respiratory secretions into the upper airways for expulsion."

Question 28

A patient is prescribed high-flow oxygen therapy. What action should the nurse take when caring for this patient?
1) Ensure the reservoir bag inflates.
2) Clear condensation from the tubing.
3) Keep the port on the face mask uncovered.
4) Position the fluid collection reservoir above face level.

Question 29

A patient being mechanically ventilated is being considered for weaning. What intervention should the nurse take at this time? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Prepare the patient to be placed on CPAP for 2 hours.
2) Prepare the patient to be placed on a T-piece for 2 hours.
3) Measure rapid shallow breathing index after 2 hours on a T-piece.
4) Lower the ventilator settings.
5) Set the ventilator to synchronized intermittent mandatory ventilation.

Question 30

A patient in the recovery phase of acute respiratory distress syndrome continues to experience difficulty with breathing. What should the nurse recognize as being the characteristics of this phase? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Development of fibrotic tissue in the alveolar capillary membrane resulting in alveolar disfigurement
2) Decreased lung compliance
3) Worsening pulmonary hypertension
4) Increased dead space ventilation
5) Formation of hyaline membranes

Question 31

The high-pressure alarm on a patient's mechanical ventilator is sounding. What action should the nurse take? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Assess if the patient needs to be suctioned.
2) Assess if the patient is biting the tube.
3) Assess if the patient has rolled onto the tube.
4) Assess for a mucous plug.
5) Assess for respiration synchrony with the ventilator.

Question 32

A patient with ARDS has PEEP added to the mechanical ventilation therapy. Which assessment finding indicates that the use of PEEP has been effective?
1) PCO₂ of 52 mm Hg
2) A PO₂ of 92 mm Hg
3) A respiratory rate of 33
4) A urine output of 50 cc/hr

Question 33

Which assessment finding indicates that a patient is ready to be weaned off of mechanical ventilation? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Unstable hemodynamics
2) Rapid shallow breathing index of 40
3) A spontaneous tidal volume of 600 cc
4) An SaO₂ of 95%
5) A respiratory rate of 18 on CPAP

Question 34

For which health condition is the use of the prone position to enhance oxygenation in a patient with acute respiratory distress syndrome contraindicated? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) A spinal injury
2) Increased intracranial pressure
3) A heart rate of 120 beats per minute with a blood pressure of 80/48 mm Hg
4) Abdominal compartment syndrome
5) Begun weaning off of mechanical ventilation

Question 35

What is important for the nurse to assess in a patient who is beginning noninvasive ventilatory support? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Patient orientation and level of alertness
2) Respiratory pattern and depth
3) Status of skin of the nose
4) Bowel sounds and presence of insufflation
5) Peripheral pulses

Question 36

A patient with acute lung injury is started on enteral nutrition. Which interventions should the nurse implement to ensure nutritional support for this patient? Select all that apply. Note: Credit will be given only if all correct choices and no incorrect choices are selected.
1) Withhold the use of the nasogastric tube until radiographic placement is confirmed.
2) Monitor for diarrhea.
3) Assess for gastric residual.
4) Keep the head of the bed elevated to at least 30 degrees.
5) Ensure the tube feeding continues uninterrupted.