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?

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?

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?

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?

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 SpO₂ of 89%. The client is increasingly lethargic. Which of the following actions should the nurse anticipate?

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?

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 PaCO₂. Which of the following assessment information will be of most concern to the nurse?

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?

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?

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?

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?

Accepted Answer

Chest physiotherapy is indicated in clients who produce more than 30 mL of sputum per day or have evidence of severe atelectasis or pulmonary infiltrates. Vancomycin therapy is not an indication for chest physio unless there is sputum present >30 mL/day. A client on a bronchodilator does not necessarily require chest physio. An increased PCO₂ level is not an indication for chest physio.

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?

Accepted Answer

The client should be positioned with the "good" lung in the dependent position to improve the match between ventilation and perfusion. The obese client's abdomen will limit respiratory excursion when sitting in the high Fowler's or tripod positions.

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?

Accepted Answer

Since agitation and confusion are frequently the initial indicators of hypoxemia, the nurse's initial action should be to assess oxygen saturation. The other actions also are appropriate, but assessment of oxygenation takes priority over other assessments and notification of the health care provider.

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?

Accepted Answer

Because barotrauma is associated with high airway pressures, the level of PEEP should be decreased. The other actions will not decrease the risk for pneumothorax.

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 (SpO₂) from 94% to 88%. Which of the following actions should the nurse implement?

Accepted Answer

Increasing oxygen flow rate usually will improve oxygen saturation in clients with ventilation-perfusion mismatch, as occurs with pulmonary embolism. Because the problem is with perfusion, actions that improve ventilation, such as deep-breathing and coughing, sitting upright, and suctioning, are not likely to improve oxygenation.

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?

Accepted Answer

The client's assessment indicates that assisted coughing is needed to help remove secretions, which will improve oxygenation. A 2-hour rest period at this time may allow the oxygen saturation to drop further. Humidification will not be helpful unless the secretions can be mobilized. Positioning on the right side may cause a further decrease in oxygen saturation because perfusion will be directed more toward the more poorly ventilated lung.

Question 17

The nurse is caring for a client who has a nursing diagnosis of ineffective airway clearance related to thick, secretions. Which of the following actions should the nurse include in the plan of care?

Accepted Answer

Since the reason for the poor airway clearance is the thick secretions, the best action will be to encourage the client to improve oral fluid intake. The use of the incentive spirometer should be more frequent in order to facilitate the clearance of the secretions. The other actions also may be helpful in improving the client's gas exchange, but they do not address the thick secretions that are causing the poor airway clearance.

Question 18

After receiving change-of-shift report, which of the following clients should the nurse assess first?

Accepted Answer

This client's history of septicemia and laboured breathing suggest the onset of ARDS, which will require rapid interventions such as administration of oxygen and use of positive pressure ventilation. The other clients also should be assessed as quickly as possible, but their assessment data are typical of their disease processes and do not suggest deterioration in their status.

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?

Accepted Answer

The PaO? indicates severe hypoxemia and respiratory failure. Rapid action is needed to prevent further deterioration of the client. Although the shallow breathing, rapid respiratory rate, and low PaCO₂ also need to be addressed, the most urgent problem is the client's poor oxygenation.

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?

Accepted Answer

Elevation of the head decreases the risk for aspiration. PEEP is frequently needed to improve oxygenation in clients receiving mechanical ventilation. Suctioning should be done only when the client assessment indicates that it is necessary. Enteral feedings should provide adequate calories for the client's high energy needs.

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

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?

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?

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?

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?

The nurse is caring for a client with respiratory failure who has a respiratory rate of 8/min and a SpO₂ of 89%. The client is increasingly lethargic. Which of the following actions should the nurse anticipate?

The nurse is admitting a client who is in possible respiratory failure with a high PaCO₂. Which of the following assessment information will be of most concern to the nurse?

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?

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?

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?

Chest physiotherapy is indicated for which of the following clients?

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?

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?

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?

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 (SpO₂) from 94% to 88%. Which of the following actions should the nurse implement?

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?

The nurse is caring for a client who has a nursing diagnosis of ineffective airway clearance related to thick, secretions. Which of the following actions should the nurse include in the plan of care?

After receiving change-of-shift report, which of the following clients should the nurse assess first?

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?

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?

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

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?

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?

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?

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?

The nurse is caring for a client with respiratory failure who has a respiratory rate of 8/min and a SpO2 of 89%. The client is increasingly lethargic. Which of the following actions should the nurse anticipate?

The nurse is admitting a client who is in possible respiratory failure with a high PaCO2. Which of the following assessment information will be of most concern to the nurse?

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?

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?

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?

Chest physiotherapy is indicated for which of the following clients?

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?

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?

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?

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 (SpO2) from 94% to 88%. Which of the following actions should the nurse implement?

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?

The nurse is caring for a client who has a nursing diagnosis of ineffective airway clearance related to thick, secretions. Which of the following actions should the nurse include in the plan of care?

After receiving change-of-shift report, which of the following clients should the nurse assess first?

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?

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?

The nurse is caring for a client with respiratory failure who has a respiratory rate of 8/min and a SpO₂ of 89%. The client is increasingly lethargic. Which of the following actions should the nurse anticipate?

The nurse is admitting a client who is in possible respiratory failure with a high PaCO₂. Which of the following assessment information will be of most concern to the nurse?

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 (SpO₂) from 94% to 88%. Which of the following actions should the nurse implement?