Question 1

When prone positioning is used in the care of a client with acute respiratory distress syndrome (ARDS), which of the following information obtained by the nurse indicates that the positioning is effective?

A)The client's PaO? is 90 mm Hg, and the SaO? is 92%.
B)Endotracheal suctioning results in minimal mucous return.
C)Sputum and blood cultures show no growth after 24 hours.
D)The skin on the client's back is intact and without redness.

Accepted Answer

The purpose of prone positioning is to improve the client's oxygenation as indicated by the PaO₂ and SaO₂. The other information will be collected but does not indicate whether prone positioning has been effective.

Question 2

To evaluate the effectiveness of prescribed therapies for a client with ventilatory failure, which of the following diagnostic tests will be most useful to the nurse?&#10;A)Chest x-rays&#10;B)Pulse oximetry&#10;C)Arterial blood gas (ABG) analysis&#10;D)Pulmonary artery pressure monitoring

Accepted Answer

ABG analysis is most useful in this setting because ventilatory failure causes problems with CO₂retention, and ABGs provide information about the PaCO₂ and pH. The other tests also may be done to help in assessing oxygenation or determining the cause of the client's ventilatory failure.

Question 3

The nurse is admitting a client with chronic obstructive pulmonary disease (COPD) who has shortness of breath and dyspnea. Which of the following assessment findings is most important to report to the health care provider?

A)The client has bibasilar lung crackles.
B)The client is sitting in the tripod position.
C)The client's respiratory rate has decreased from 30 to 10 breaths/minute.
D)The client's pulse oximetry indicates an O? saturation of 91%.

Accepted Answer

A decrease in respiratory rate in a client with respiratory distress suggests the onset of fatigue and a high risk for respiratory arrest. Therefore immediate action such as positive pressure ventilation is needed. Clients who are experiencing respiratory distress frequently sit in the tripod position because it decreases the work of breathing. Crackles in the lung bases may be the baseline for a client with COPD. An oxygen saturation of 91% is common in clients with COPD and will provide adequate gas exchange and tissue oxygenation.

Question 4

The nurse obtains the vital signs for a client admitted 2 days ago with gram-negative sepsis: temperature 38.4°C (101.1°F), blood pressure 90/56 mm Hg, pulse 92 beats/minute, respirations 34/minute. Which of the following actions should the nurse take next?

A)Administer the scheduled IV antibiotic.
B)Give the PRN acetaminophen 650 mg.
C)Obtain oxygen saturation using pulse oximetry.
D)Notify the health care provider of the client's vital signs.

Accepted Answer

The client's increased respiratory rate in combination with the admission diagnosis of gram-negative sepsis indicates that acute respiratory distress syndrome (ARDS) may be developing. The nurse should check for hypoxemia, a hallmark of ARDS. The health care provider should be notified after further assessment of the client. Administration of the scheduled antibiotic and administration of acetaminophen also will be done, but they are not the highest priority for a client who may be developing ARDS.

Question 5

The nurse is caring for a client with respiratory failure who has a respiratory rate of 8/min and a SpO? of 89%. The client is increasingly lethargic. Which of the following actions should the nurse anticipate?

A)Administration of 100% oxygen by non-rebreather mask
B)Endotracheal intubation and positive pressure ventilation
C)Insertion of a mini-tracheostomy with frequent suctioning
D)Initiation of bilevel positive pressure ventilation (BiPAP)

Accepted Answer

The client's lethargy, low respiratory rate, and SpO₂ indicate the need for mechanical ventilation with ventilator-controlled respiratory rate. Administration of high flow oxygen will not be helpful because the client's respiratory rate is so low. Insertion of a mini-tracheostomy will facilitate removal of secretions, but it will not improve the client's respiratory rate or oxygenation. BiPAP requires that the client initiate an adequate respiratory rate to allow adequate gas exchange.

Question 6

The nurse is caring for a client who develops increasing dyspnea and hypoxemia 2 days after having cardiac surgery. To determine whether the client has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by left ventricular failure, thenursewill anticipate assisting with which of the following actions?

A)Inserting a pulmonary artery catheter
B)Obtaining a ventilation-perfusion scan
C)Drawing blood for arterial blood gases
D)Positioning the client for a chest radiograph

Accepted Answer

Pulmonary artery wedge pressures are normal in the client with ARDS because the fluid in the alveoli is caused by increased permeability of the alveolar-capillary membrane rather than by the backup of fluid from the lungs (as occurs in cardiogenic pulmonary edema).
The other tests will not help in differentiating cardiogenic from noncardiogenic pulmonary edema.

Question 7

The nurse is admitting a client who is in possible respiratory failure with a high PaCO?. Which of the following assessment information will be of most concern to the nurse?&#10;A)The client is somnolent.&#10;B)The client's SpO? is 90%.&#10;C)The client complains of weakness.&#10;D)The client's blood pressure is 162/94 mmHg.

Accepted Answer

Increasing somnolence will decrease the client's respiratory rate and further increase the PaCO₂ and respiratory failure. Rapid action is needed to prevent respiratory arrest. An SpO₂ of 90%, weakness, and elevated blood pressure all require ongoing monitoring but are not indicators of possible impending respiratory arrest.

Question 8

The nurse is caring for a client who was hospitalized 2 days earlier with aspiration pneumonia. Which of the following assessment information is most important to communicate to the health care provider?

A)Cough that is productive of blood-tinged sputum
B)Scattered crackles throughout the posterior lung bases
C)Temperature of 38.6°C (101.5°C) after 2 days of IV antibiotic therapy
D)Oxygen saturation (SpO?) has dropped to 90% with administration of 100% O? by non-rebreather mask

Accepted Answer

The client's low SpO₂ despite receiving a high fraction of inspired oxygen (FIO₂) indicates the possibility of acute respiratory distress syndrome (ARDS). The client's blood-tinged sputum and scattered crackles are not unusual in a client with pneumonia, although they do require continued monitoring. The continued temperature elevation indicates a possible need to change antibiotics, but this is not as urgent a concern as the progression toward hypoxemia despite an increase in O₂ flow rate.

Question 9

Which of the following assessment findings by the nurse when caring for a client with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP) indicates that the PEEP may need to be decreased?

A)The client has subcutaneous emphysema.
B)The client has a sinus bradycardia with a rate of 52.
C)The client's PaO? is 50 mm Hg and the SaO? is 88%.
D)The client has bronchial breath sounds in both the lung fields.

Accepted Answer

The subcutaneous emphysema indicates barotrauma caused by positive pressure ventilation and PEEP. Bradycardia, hypoxemia, and bronchial breath sounds are all concerns and will need to be addressed, but they are not indications that PEEP should be reduced.

Question 10

Which of the following statements by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the family members of a client with ARDS is correct?&#10;A)&#34;PEEP will prevent fibrosis of the lung from occurring.&#34;&#10;B)&#34;PEEP will push more air into the lungs during inhalation.&#34;&#10;C)&#34;PEEP allows the ventilator to deliver 100% oxygen to the lungs.&#34;&#10;D)&#34;PEEP prevents the lung air sacs from collapsing during exhalation.&#34;

Accepted Answer

By preventing alveolar collapse during expiration, PEEP improves gas exchange and oxygenation. PEEP will not prevent the fibrotic changes that occur with ARDS, push more air into the lungs, or change the fraction of inspired oxygen (FIO₂) delivered to the client.

Question 11

Chest physiotherapy is indicated for which of the following clients?&#10;A)Takes a bronchodilator&#10;B)Produces 40 mL of sputum per 24 hours&#10;C)Has an increased PCO? level&#10;D)Is taking vancomycin

Accepted Answer

The answer of Chest physiotherapy is indicated for which of...

Question 12

The nurse is caring for an obese client with left lower lobe pneumonia. Which of the following positions should the nurse place the client in for optimal gas exchange?&#10;A)Left lateral&#10;B)Right lateral&#10;C)Tripod position.&#10;D)High Fowler's position

Accepted Answer

The answer of The nurse is caring for an obese...

Question 13

The nurse is assessing a client with chronic lung disease and finds a sudden onset of agitation and confusion. Which of the following actions should the nurse take first?&#10;A)Check pupil reaction to light.&#10;B)Notify the health care provider.&#10;C)Attempt to calm and reassure the client.&#10;D)Assess oxygenation using pulse oximetry.

Accepted Answer

The answer of The nurse is assessing a client with...

Question 14

The nurse is caring for a client with acute respiratory distress syndrome (ARDS) who is intubated, receiving mechanical ventilation and has developed a pneumothorax. Which of the following actions will the nurse anticipate taking?

A)Lower the positive end-expiratory pressure (PEEP).
B)Increase the fraction of inspired oxygen (FIO?).
C)Suction more frequently.
D)Increase the tidal volume.

Accepted Answer

The answer of The nurse is caring for a client...

Question 15

The nurse is caring for a client who has been admitted with a pulmonary embolism and notes a change in the client's oxygen saturation (SpO?) from 94% to 88%. Which of the following actions should the nurse implement?

A)Increase the oxygen flow rate.
B)Suction the client's oropharynx.
C)Assist the client to cough and deep breathe.
D)Help the client to sit in a more upright position.

Accepted Answer

The answer of The nurse is caring for a client...

Question 16

The pulse oximetry for a client with right lower lobe pneumonia indicates an oxygen saturation of 90%. The client has rhonchi, a weak cough effort, and complains of fatigue. Which of the following actions is best for the nurse to take?

A)Position the client on the right side.
B)Place a humidifier in the client's room.
C)Assist the client with staged coughing.
D)Schedule a 2-hour rest period for the client.

Accepted Answer

The answer of The pulse oximetry for a client with...

Question 17

The nurse is caring for a client who has been admitted with a pulmonary embolism and notes a change in the client's oxygen saturation (SpO?) from 94% to 88%. Which of the following actions should the nurse implement?

A)Increase the oxygen flow rate.
B)Suction the client's oropharynx.
C)Assist the client to cough and deep breathe.
D)Help the client to sit in a more upright position.

Accepted Answer

The answer of The nurse is caring for a client...

Question 18

After receiving change-of-shift report, which of the following clients should the nurse assess first?&#10;A)A client with cystic fibrosis who has thick, green-coloured sputum&#10;B)A client with pneumonia who has coarse crackles in both lung bases&#10;C)A client with emphysema who has an oxygen saturation of 91% to 92%&#10;D)A client with septicemia who has intercostal and suprasternal retractions

Accepted Answer

The answer of After receiving change-of-shift report, which of the...

Question 19

The nurse is caring for a client who came to the emergency department with acute respiratory distress. Which of the following information requires the most rapid action by the nurse?&#10;A)Respiratory rate is 32 breaths/minute.&#10;B)Pattern of breathing is shallow.&#10;C)The client's PaO? is 45 mm Hg.&#10;D)The client's PaCO? is 34 mm Hg.

Accepted Answer

The answer of The nurse is caring for a client...

Question 20

To decrease the risk for ventilator-associated pneumonia, which of the following actions should the nurse include in the plan of care for a client who requires intubation and mechanical ventilation?&#10;A)Avoid use of positive end-expiratory pressure (PEEP).&#10;B)Suction every 2 hours.&#10;C)Elevate head of bed to 45 degrees.&#10;D)Give enteral feedings at no more than 10 mL/hour.

Accepted Answer

The answer of To decrease the risk for ventilator-associated pneumonia,...

Question 21

The nurse is caring for a client with chronic hypercapnia and is to receive supplemental oxygen. Which of the following prescribed actions should the nurse implement?&#10;A)Venturi mask at 48%&#10;B)Nasal cannula at 1-2 L/minute&#10;C)Noninvasive ventilation&#10;D)Face mask at 4-5 L/minute

Accepted Answer

The answer of The nurse is caring for a client...

Question 22

A client with ARDS who is receiving mechanical ventilation using synchronized intermittent mandatory ventilation (SIMV) has settings of fraction of inspired oxygen (FIO?) 80%, tidal volume 500, rate 18, and positive end-expiratory pressure (PEEP) 5 cm.Whichof the following assessment findings is most important for the nurse to report to the health care provider?

A)Oxygen saturation 99%
B)Client respiratory rate 22 breaths/minute
C)Crackles audible at lung bases
D)Apical pulse rate 104 beats/minute

Accepted Answer

The answer of A client with ARDS who is receiving...

Question 23

The nurse is caring for a client with hypoxemia and a PaO?/FiO? ratio of 170 while being administered oxygen 8 L/minute via mask. Which of the following information is accurate in relation to the client's situation?

A)Is at risk for ARDS
B)Also has an increased PaCO? level
C)Should be prepared for mechanical ventilation
D)Requires packed red cells as soon as possible

Accepted Answer

The answer of The nurse is caring for a client...

Deck 70: Nursing Management Respiratory Failure and Acute Respiratory Distress Syndrome