Module 13: Resp. Failure ARDS NCLEX Questions

Module 13: Resp. Failure & ARDS NCLEX Questions

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49 terms Forever_Aela5102 Preview NCLEX Acute Respiratory Failure an...22 terms EmSayPreview ARDS nclex questions 33 terms almachengray Preview Respira 43 terms Set A firefighter who was involved in extinguishing a house fire is being treated for smoke inhalation. He develops severe hypoxia 48 hours after the incident, requiring intubation and mechanical ventilation. Which of the following conditions has he most likely developed?

• Acute respiratory distress syndrome (ARDS).
• Atelectasis.
• Bronchitis.
• Pneumonia.

A.Severe hypoxia after smoke inhalation typically is related to ARDS. The other choices aren't typically associated with smoke inhalation A male patient is admitted to the health care facility for treatment of chronic obstructive pulmonary disease.Which nursing diagnosis is most important for this patient?

• Activity intolerance related to fatigue
• Anxiety related to actual threat to health status
• Risk for infection related to retained secretions
• Impaired gas exchange related to airflow obstruction

D.A patient airway and an adequate breathing pattern are the top priority for any patient, making "impaired gas exchange related to airflow obstruction" the most important nursing diagnosis. The other options also may apply to this patient but less important.For a patient with advance chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange?

• Encouraging the patient to drink three glasses of fluid

daily

• Keeping the patient in semi-fowler's position
• Using a high-flow venture mask to deliver oxygen as

prescribe

• Administering a sedative, as prescribe

C.The patient with COPD retains carbon dioxide, which inhibits stimulation of breathing by the medullary center in the brain. As a result, low oxygen levels in the blood stimulate respiration, and administering unspecified, unmonitored amounts of oxygen may depress ventilation. To promote adequate gas exchange, the nurse should use a Venturi mask to deliver a specified, controlled amount of oxygen consistently and accurately. Drinking three glasses of fluid daily would not affect gas exchange or be sufficient to liquefy secretions, which are common in COPD. Patients with COPD and respiratory distress should be places in high- Fowler's position and should not receive sedatives or other drugs that may further depress the respiratory center.

A male patient's X-ray result reveals bilateral white-outs, indicating adult respiratory distress syndrome (ARDS).

This syndrome results from:

• Cardiogenic pulmonary edema
• Respiratory alkalosis
• Increased pulmonary capillary permeability
• Renal failure

C.ARDS results from increased pulmonary capillary permeability, which leads to noncardiogenic pulmonary edema. In cardiogenic pulmonary edema, pulmonary congestion occurs secondary toheart failure. In the initial stage of ARDS, respiratory alkalosis may arise secondary to hyperventilation; however, it does not cause ARDS. Renal failure does not cause ARDS, either.Nurse Oliver is caring for a client immediately after removal of the endotracheal tube. The nurse reports which of the following signs immediately if experienced by the client?

• Stridor
• Occasional pink-tinged sputum
• A few basilar lung crackles on the right
• Respiratory rate 24 breaths/min

A.The nurse reports stridor to the physician immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway edema and places the client at risk for airway obstruction.Options B, C, and D are not signs that require immediate notification of the physician.A nurse instructs a female client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-

lip breathing is to:

• Promote oxygen intake
• Strengthen the diaphragm
• Strengthen the intercostal muscles
• Promote carbon dioxide elimination

D.Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options A, B, and C are not the purposes of this type of breathing.A nurse is caring for a male client with acute respiratory distress syndrome. Which of the following would the nurse expect to note in the client?

• Pallor
• Low arterial PaO2
• Elevated arterial PaO2
• Decreased respiratory rate

B.The earliest clinical sign of acute respiratory distress syndrome is an increased respiratory rate. Breathing becomes labored, and the client may exhibit air hunger, retractions, and cyanosis. Arterial blood gas analysis reveals increasing hypoxemia, with a PaO2 lower than 60 mm Hg.A male adult client is suspected of having a pulmonary embolus. A nurse assesses the client, knowing that which of the following is a common clinical manifestation of pulmonary embolism?

• Dyspnea
• Bradypnea
• Bradycardia
• Decreased respirations

A.The common clinical manifestations of pulmonary embolism are tachypnea, tachycardia, dyspnea, and chest pain.A black client with asthma seeks emergency care for acute respiratory distress. Because of this client's dark skin, the nurse should assess for cyanosis by inspecting

the:

• Lips.
• Mucous membranes.
• Nail beds.
• Earlobes.

B.Skin color doesn't affect the mucous membranes. The lips, nail beds, and earlobes are less reliable indicators of cyanosis because they're affected by skin color.

For a male client with an endotracheal (ET) tube, which nursing action is most essential?

• Auscultating the lungs for bilateral breath sounds
• Turning the client from side to side every 2 hours
• Monitoring serial blood gas values every 4 hours
• Providing frequent oral hygiene

A.For a client with an ET tube, the most important nursing action is auscultating the lungs regularly for bilateral breath sounds to ensure proper tube placement and effective oxygen delivery. Although the other options are appropriate for this client, they're secondary to ensuring adequate oxygenation.The nurse assesses a male client's respiratory status.Which observation indicates that the client is experiencing difficulty breathing?

• Diaphragmatic breathing
• Use of accessory muscles
• Pursed-lip breathing
• Controlled breathing

B.The use of accessory muscles for respiration indicates the client is having difficulty breathing. Diaphragmatic and pursed-lip breathing are two controlled breathing techniques that help the client conserve energy.A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis?

• pH, 5.0; PaCO2 30 mm Hg
• pH, 7.40; PaCO2 35 mm Hg
• pH, 7.35; PaCO2 40 mm Hg
• pH, 7.25; PaCO2 50 mm Hg

D.In respiratory acidosis, ABG analysis reveals an arterial pH below 7.35 and partial pressure of arterial carbon dioxide (PaCO2) above 45 mm Hg. Therefore, the combination of a pH value of 7.25 and a PaCO2 value of 50 mm Hg confirms respiratory acidosis. A pH value of 5.0 with a PaCO2 value of 30 mm Hg indicates respiratory alkalosis. Options B and C represent normal ABG values, reflecting normal gas exchange in the lungs.A male client admitted to an acute care facility with pneumonia is receiving supplemental oxygen, 2 L/minute via nasal cannula. The client's history includes chronic obstructive pulmonary disease (COPD) and coronary artery disease. Because of these history findings, the nurse closely monitors the oxygen flow and the client's respiratory status. Which complication may arise if the client receives a high oxygen concentration?

• Apnea
• Anginal pain
• Respiratory alkalosis
• Metabolic acidosis

A.Hypoxia is the main breathing stimulus for a client with COPD. Excessive oxygen administration may lead to apnea by removing that stimulus. Anginal pain results from a reduced myocardial oxygen supply. A client with COPD may have anginal pain from generalized vasoconstriction secondary to hypoxia; however, administering oxygen at any concentration dilates blood vessels, easing anginal pain. Respiratory alkalosis results from alveolar hyperventilation, not excessive oxygen administration. In a client with COPD, high oxygen concentrations decrease the ventilatory drive, leading to respiratory acidosis, not alkalosis. High oxygen concentrations don't cause metabolic acidosis.Which of the following are early s/sx of ARDS?

• Retractions - not always (tissues between ribs and

above sternum pull in)

• Dyspneic
• Non-productive cough
• Accessory muscle used
• Pallor or cyanosis
• Significant CXR changes; pulmonary infiltrates
• Restlessness
• CXR clear
• Respiratory alkalosis
• Respiratory acidosis

B, C,E, G, H, I

A patient is diagnosed with a large pulmonary embolism.When explaining to the patient what has happened to cause respiratory failure, which information will the nurse include?

• "Oxygen transfer into your blood is slow because of

thick membranes between the small air sacs and the lung circulation."

• "Thick secretions in your small airways are blocking air

from moving into the small air sacs in your lungs."

• "Large areas of your lungs are getting good blood flow

but are not receiving enough air to fill the small air sacs."

• "Blood flow though some areas of your lungs is

decreased even though you are taking adequate breaths." D.A pulmonary embolus limits blood flow but does not affect ventilation, leading to a ventilation-perfusion mismatch. The response beginning, "Oxygen transfer into your blood is slow because of thick membranes" describes a diffusion problem.The remaining two responses describe ventilation-perfusion mismatch with adequate blood flow but poor ventilation.A patient is brought to the emergency department unconscious following a barbiturate overdose. Which potential complication will the nurse include when developing the plan of care?

• Hypercapnic respiratory failure related to decreased

ventilatory effort

• Hypoxemic respiratory failure related to diffusion

limitations

• Hypoxemic respiratory failure related to shunting of

blood .

• Hypercapnic respiratory failure related to increased

airway resistance A.The patient with an opioid overdose develops hypercapnic respiratory failure as a result of the decrease in respiratory rate and depth. Diffusion limitations, blood shunting, and increased airway resistance are not the primary pathophysiology causing the respiratory failure.A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department complaining of acute respiratory distress. When monitoring the patient, which assessment by the nurse will be of most concern?

• The patient is sitting in the tripod position.
• The patient has bibasilar lung crackles.
• The patient's pulse oximetry indicates an O2 saturation

of 91%.

• The patient's respiratory rate has decreased from 30

to 10/min.D.A decrease in respiratory rate in a patient with respiratory distress suggests the onset of fatigue and a high risk for respiratory arrest; therefore, the nurse will need to take immediate action. Patients 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 patient with COPD. An oxygen saturation of 91% is common in patients with COPD and will provide adequate gas exchange and tissue oxygenation A finding indicating to the nurse that a 22-year-old patient with respiratory distress is in acute respiratory failure includes a

• shallow breathing pattern.
• partial pressure of arterial oxygen (PaO2) of 45 mm

Hg.

• partial pressure of carbon dioxide in arterial gas

(PaCO2) of 34 mm Hg.

• respiratory rate of 32/min.

B.The PaO2 indicates severe hypoxemia and that the nurse should take immediate action to correct this problem. Shallow breathing, rapid respiratory rate, and low PaCO2 can be caused by other factors, such as anxiety or pain.