NCLEX: PHYSIOLOGICAL INTEGRITY

NCLEX: PHYSIOLOGICAL INTEGRITY

Nursing Management: Respiratory Failure and Acute

Respiratory Distress Syndrome Test Bank.100% Knowledge booster.

Nursing Management: Respiratory Failure and Acute Respiratory Distress Syndrome

Test Bank

MULTIPLE CHOICE

• To evaluate the effectiveness of ordered interventions for a patient with ventilatory failure,

which diagnostic test will be most useful to the nurse?

• Chest x-ray
• Oxygen saturation
• Arterial blood gas analysis
• Central venous pressure monitoring

ANS: C

Arterial blood gas (ABG) analysis is most useful in this setting because ventilatory failure causes problems with CO2 retention, and ABGs provide information about the PaCO2 and pH.The other tests may also be done to help in assessing oxygenation or determining the cause of the patient’s ventilatory failure.DIF: Cognitive Level: Apply (application) REF: 1661 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

• While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes

a change in the patient’s oxygen saturation (SpO2) from 94% to 88%. Which action should the nurse take next?

• Increase the oxygen flow rate.
• Suction the patient’s oropharynx.
• Instruct the patient to cough and deep breathe.
• Help the patient to sit in a more upright position.

ANS: A

Increasing oxygen flow rate will usually improve oxygen saturation in patients 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.

DIF: Cognitive Level: Apply (application) REF: 1656 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

• A patient with respiratory failure has a respiratory rate of 6 breaths/minute and an oxygen

saturation (SpO2) of 88%. The patient is increasingly lethargic. Which intervention will the nurse anticipate?

• Administration of 100% oxygen by non-rebreather mask
• Endotracheal intubation and positive pressure ventilation
• Insertion of a mini-tracheostomy with frequent suctioning
• Initiation of continuous positive pressure ventilation (CPAP)

ANS: B

The patient’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 patient’s respiratory rate is so low. Insertion of a mini-tracheostomy will facilitate removal of secretions, but it will not improve the patient’s respiratory rate or oxygenation. CPAP requires that the patient initiate an adequate respiratory rate to allow adequate gas exchange.

DIF: Cognitive Level: Apply (application) REF: 1658 | 1662 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

• The oxygen saturation (SpO2) for a patient with left lower lobe pneumonia is 90%. The

patient has rhonchi, a weak cough effort, and complains of fatigue. Which action is a priority for the nurse to take?

• Position the patient on the left side.
• Assist the patient with staged coughing.
• Place a humidifier in the patient’s room.
• Schedule a 2-hour rest period for the patient.

ANS: B

The patient’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 left side may cause a further decrease in oxygen saturation because perfusion will be directed more toward the more poorly ventilated lung.DIF: Cognitive Level: Apply (application) REF: 1661-1662 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

• A nurse is caring for an obese patient with right lower lobe pneumonia. Which position will

be best to improve gas exchange?

• On the left side
• On the right side
• In the tripod position
• In the high-Fowler’s position

ANS: A

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

DIF: Cognitive Level: Apply (application) REF: 1662 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

• When admitting a patient with possible respiratory failure with a high PaCO2, which

assessment information should be immediately reported to the health care provider?

• The patient is somnolent.
• The patient complains of weakness.
• The patient’s blood pressure is 164/98.
• The patient’s oxygen saturation is 90%.

ANS: A

Increasing somnolence will decrease the patient’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.DIF: Cognitive Level: Apply (application) REF: 1660 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

• A patient with acute respiratory distress syndrome (ARDS) and acute kidney injury has the

following medications ordered. Which medication should the nurse discuss with the health care provider before giving?

• Pantoprazole (Protonix) 40 mg IV
• Gentamicin (Garamycin) 60 mg IV
• Sucralfate (Carafate) 1 g per nasogastric tube
• Methylprednisolone (Solu-Medrol) 60 mg IV

ANS: B

Gentamicin, which is one of the aminoglycoside antibiotics, is potentially nephrotoxic, and the nurse should clarify the drug and dosage with the health care provider before administration. The other medications are appropriate for the patient with ARDS.

DIF: Cognitive Level: Apply (application) REF: 1669 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

• A patient develops increasing dyspnea and hypoxemia 2 days after heart surgery. To

determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by heart failure, the nurse will plan to assist with

• obtaining a ventilation-perfusion scan.
• drawing blood for arterial blood gases.
• insertion of a pulmonary artery catheter.
• positioning the patient for a chest x-ray.

ANS: C

Pulmonary artery wedge pressures are normal in the patient 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.

DIF: Cognitive Level: Apply (application) REF: 1667 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

• A nurse is caring for a patient with ARDS who is being treated with mechanical ventilation

and high levels of positive end-expiratory pressure (PEEP). Which assessment finding by the nurse indicates that the PEEP may need to be reduced?

• The patient’s PaO2 is 50 mm Hg and the SaO2 is 88%.
• The patient has subcutaneous emphysema on the upper thorax.
• The patient has bronchial breath sounds in both the lung fields.
• The patient has a first-degree atrioventricular heart block with a rate of 58.

ANS: B