Resp Failure & ARDS NCLEX

Resp Failure & ARDS NCLEX 5.0 (10 reviews) Students also studied Terms in this set (21) Harrisburg Area Community College NURS 250 Save NCLEX Acute Respiratory Failure an...22 terms EmSayPreview

Lewis Chapter 67: Acute Respiratory ...

49 terms Forever_Aela5102 Preview Respiratory Failure NCLEX Question...19 terms Brittneybarbuto123 Preview Nclex Q 32 terms kar Which is a proper nursing action for a patient in acute respiratory failure?

• Administer 100% oxygen to an intubated patient until

the pathology has resolved.

• Provide chest physical therapy for patients who

produce more than 30 mL of sputum per day.

• Use continuous positive airway pressure (CPAP) if the

patient has weak or absent respirations.

• Administer packed red blood cells to maintain the

hemoglobin level at 7 g/dL or higher.

• Provide chest physical therapy for patients who produce more than 30 mL of

sputum per day.Chest physical therapy is indicated for patients who produce more than 30 mL of sputum per day or have evidence of atelectasis or pulmonary infiltrates. The selected oxygen delivery system must also maintain PaO2 equal to or more than 55 to 60 mm HG and SaO2 equal or greater than 90% at the lowest O2 concentration possible. High oxygen concentrations replace the nitrogen gas normally present in the alveoli, causing instability and atelectasis. In intubated patients, exposure to 60% or more oxygen for longer than 48 hours poses a significant risk for oxygen toxicity. Noninvasive positive-pressure ventilation such as CPAP is not appropriate for patients who have weak or no respirations (are not inhaling). The hemoglobin level should be equal to or greater than 9 g/dL to ensure adequate oxygen saturation.What distinguishes hypercapnic respiratory failure from hypoxemic respiratory failure?

• Low oxygen saturation despite administration of

supplemental oxygen

• Acidemia for which the body cannot compensate
• Respiration rate greater than 30 breaths/minute
• Heart rate increases above 100 beats/minute
• Acidemia for which the body cannot compensate

Hypercapnic respiratory failure is PaCO2 greater than 48 mm Hg in combination with acidemia. The body cannot compensate for the acidemia. Hypoxemic respiratory failure is a PaO2 less than 60 mm Hg despite receiving an inspired oxygen concentration greater than or equal to 60%. The respiratory rate and heart rate are not part of the definitions of these two conditions.

Which patient is most likely going into respiratory failure?

• A patient who report that he feels short of breath while

eating

• A patient with the following arterial blood gas values

over the past 3 hours: pH 7.50, 7.45, and 7.40

• A patient with an oxygen saturation value of 93%
• A patient with chronic obstructive pulmonary disease

(COPD) who has distant breath sounds

• A patient with the following arterial blood gas values over the past 3 hours: pH

7.50, 7.45, and 7.40 Manifestations of respiratory failure are related to the extent of change in PaO2 or PaCO2, the rapidity of change, and ability to compensate. It is important to monitor trends. Shortness of breath is a subjective report, and it can have many causes. A single borderline oxygen saturation reading is not as indicative of failure as a negative trend. Because of air trapping with COPD, the breath sounds are typically distant.A patient with a severe acute asthma exacerbation presents to the emergency department. Over the next hour, the patient remains in respiratory distress, but the respirations have slowed. What is the best explanation?

• The patient is developing respiratory muscle fatigue.
• The respirations are exchanging oxygen and carbon

dioxide more efficiently.

• The patient's anxiety level is lessening.
• The body has compensated by retaining sodium

bicarbonate.

• The patient is developing respiratory muscle fatigue.

A rapid respiratory rate requires a substantial amount of work. Change from a rapid rate to a slower rate in a patient in acute respiratory distress suggests extreme progression of respiratory muscle fatigue and increased probability of respiratory arrest. Ventilatory exchange, without other indications of improvement, is decreased. As long as the patient is in distress, there is no evidence that anxiety would lessen, and hypoxia would increase anxiety. Compensation through the renal system takes days.Which patient is having the most difficulty breathing?

• The patient who reports one-pillow orthopnea

B. The patient with an inspiratory to expiratory ratio of 1:2

• The patient who speaks a sentence before breathing
• The patient with paradoxic breathing
• The patient with paradoxic breathing

Paradoxic breathing indicates severe distress. The thorax and abdomen normally move outward on inspiration and inward on exhalation. During paradoxic breathing, the abdomen and chest move in the opposite manner, and the pattern results from maximal use of the accessory muscles of respiration. Orthopnea, measured by the number of pillows needed to breathe comfortably, is associated with the use of one to four pillows. One pillow indicates a minor condition. Normal inspiratory to expiratory ratio is 1:2. Speaking in sentences before having to take a breath indicates mild or no distress.Which signs and symptoms differentiate hypoxemic respiratory failure from hypercapnic respiratory failure (select all that apply)?

• Cyanosis
• Tachypnea
• Morning headache
• Paradoxic breathing
• Pursed-lip breathing
• Cyanosis
• Tachypnea
• Paradoxic breathing

Clinical manifestations that occur with hypoxemic respiratory failure include cyanosis, tachypnea, and paradoxic chest or abdominal wall movement with the respiratory cycle. Clinical manifestations of hypercapnic respiratory failure include morning headache, pursed-lip breathing, and decreased or increase respiratory rate with shallow breathing.The oxygen delivery system chosen for the patient in acute respiratory failure should

• always be a low-flow device, such as a nasal cannula.
• correct the PaO2 to a normal level as quickly as

possible.

• administer positive-pressure ventilation to prevent

CO2 narcosis.

• maintain the PaO2 at ≥60 mm Hg at the lowest O2

concentration possible.

• maintain the PaO2 at ≥60 mm Hg at the lowest O2 concentration possible.

The selected oxygen delivery system must maintain PaO2 at 55 to 60 mm Hg and SaO2 at 90% or greater at the lowest oxygen concentration possible.

You are admitting a 45-year-old asthmatic patient in acute respiratory distress. You auscultate the patient's lungs and notice cessation of inspiratory wheezing. The patient has not yet received any medication. What does this finding suggest?

• Spontaneous resolution of the acute asthma attack
• An acute development of bilateral pleural effusions
• Airway constriction requiring intensive interventions
• Overworked intercostal muscles resulting in poor air

exchange

• Airway constriction requiring intensive interventions

When the patient in respiratory distress has inspiratory wheezing that ceases, it is an indication of airway obstruction, and it requires emergency action to restore the airway.You are caring for a patient who is admitted with a barbiturate overdose. The patient is unresponsive, with a blood pressure of 90/60 mm Hg, apical pulse of 110 beats/minute, and respiratory rate of 8 breaths/minute.Based on the initial assessment findings, you recognize that the patient is at risk for which type of respiratory failure?

• Hypoxemic respiratory failure related to shunting of

blood

• Hypoxemic respiratory failure related to diffusion

limitation

• Hypercapnic respiratory failure related to alveolar

hypoventilation

• Hypercapnic respiratory failure related to increased

airway resistance

• Hypercapnic respiratory failure related to alveolar hypoventilation

The patient's respiratory rate is decreased because of barbiturate overdose, which causes respiratory depression. The patient is at risk for hypercapnic respiratory failure resulting from the decreased respiratory rate and decreased CO2 exchange.You are providing care for an elderly patient who has a low PaO2 as a result of worsening left-sided pneumonia.Which nursing intervention will help the patient mobilize his secretions?

• Augmented coughing or huff coughing
• Positioning the patient to lie on his left side
• Frequent and aggressive nasopharyngeal suctioning
• Application of noninvasive positive-pressure

ventilation (NIPPV)

• Augmented coughing or huff coughing

Augmented coughing and huff coughing techniques may aid the patient in the mobilization of secretions. If placed in a side-lying position, the patient should be positioned on his right side (good lung down). Suctioning may be indicated, but it should always be performed cautiously because of the risk of hypoxia. NIPPV is inappropriate in the treatment of patients with excessive secretions.For which patient would NIPPV be an appropriate intervention to promote oxygenation?

• A patient's whose cardiac output and blood pressure

are unstable

• A patient whose respiratory failure is caused by a head

injury with loss of consciousness

• A patient with a diagnosis of cystic fibrosis and who is

producing copious secretions

• A patient who is experiencing respiratory failure as a

result of the progression of myasthenia gravis

• A patient who is experiencing respiratory failure as a result of the progression

of myasthenia gravis NIPPV is most effective in treating patients with respiratory failure due to chest wall and neuromuscular disease. It is not recommended for patients who are experiencing cardiac instability, decreased level of consciousness, or excessive secretions.

You are aware of the value of using a mini-tracheostomy to facilitate suctioning when patients are unable to independently mobilize their secretions. For which patient is the use of a mini-tracheostomy indicated?

• A patient whose recent ischemic stroke has resulted in

the loss of his gag reflex

• A patient who requires long-term mechanical

ventilation as the result of a spinal cord injury

• A patient whose increased secretions are the result of

community-acquired pneumonia

• A patient with a head injury who has developed

aspiration pneumonia

• A patient whose increased secretions are the result of community-acquired

pneumonia It is probably appropriate to suction a patient with pneumonia using a mini- tracheostomy if blind suctioning is ineffective or difficult. An absent or compromised gag reflex, long-term ventilation, and a history of aspiration contraindicates the use of a mini-tracheostomy.Which intervention is key to preventing ventilator- associated pneumonia as a complication in a patient with acute respiratory distress syndrome (ARDS)?

• Scheduled prophylactic nasopharyngeal suctioning
• Instilling normal saline down the endotracheal tube to

loosen secretions

• Providing frequent mouth care and oral hygiene
• Using high tidal volumes on the ventilator
• Providing frequent mouth care and oral hygiene

A frequent complication of ARDS is ventilator-associated pneumonia. Preventative strategies include elevating head-of-bed 30-45 degrees and strict infection control measures such as frequent hand washing, use of in-line suction, and frequent mouth care and oral hygiene. Suctioning is done only as needed to prevent stimulating excess secretions. Instilling normal saline does not loosen secretions and can cause hypoxia. It is not recommended. High tidal volumes can lead to barotrauma.What pathophysiologic condition can result in ARDS?

• Damage to the alveolar-capillary membrane
• Copious exudates production
• Airway spasms and vasoconstriction
• Change in the inspiratory-to-expiratory ratio
• Damage to the alveolar-capillary membrane

In ARDS, there is damage to the alveolar-capillary membrane, although the exact mechanism is not known. The damage results in increased pulmonary capillary membrane permeability, destruction of elastic and collagen, formation of pulmonary microemboli, and pulmonary artery vasoconstriction. These changes produce increased fluid accumulation and decreased lung compliance.Temporary narrowing of the airway is seen in asthma. Exudate production is seen with pneumonia or chronic obstructive pulmonary disease (COPD). The cause does not involve a change in ventilation, although there may eventually be some alteration due to respiratory distress.Which is a classic finding for a patient with ARDS?

• Hypoxemia despite increased oxygen administration
• Bronchodilators ordered to relieve airway spasms
• Development of Kussmaul respirations
• Development of Cheyne-Stokes respirations
• Hypoxemia despite increased oxygen administration

The hallmark of ARDS is hypoxemia despite increased FIO2 by mask, cannula, or endotracheal tube. Bronchodilators are used for asthma. Kussmaul respirations are caused by metabolic acidosis in diabetic ketoacidosis. Cheyne-Stokes respirations are a stairstep respiratory pattern with periods of apnea related to the body being stimulated by high CO2 levels to breathe. It is seen in patients with increased intracranial pressure.Which is part of the nursing management for ARDS?

• Aggressive use of intravenous (IV) fluids
• Administration of a β-blocker
• Use of positive end-expiratory pressure (PEEP)
• Use of the lateral recumbent position
• Use of positive end-expiratory pressure (PEEP)

In ARDS, higher levels of PEEP may be used. It increases the functional residual capacity (FRC) and opens collapsed alveoli. The issues in ARDS treatment are respiratory related, not fluid deficit. β-Blockers are part of myocardial infarction management, not ARDS. Some ARDS patients do better when placed in a prone position instead of a supine position. In the supine position, the heart places pressure on the pleural cavity. Changing the patient to a prone position allows air- filled, nonatelectatic alveoli in the ventral portion of the lung to become dependent.