Chapter 32: Acute Respiratory Failure and Acute Respiratory Distress Syndrome Harding: Lewis’s Medical-Surgical Nursing, 12th Edition

1. Which diagnostic test would provide the nurse with the most specific information to evaluate the effectiveness of interventions for a patient with ventilatory failure?

a. Chest x-ray

b. O2 saturation

c. Arterial blood gases

d. Central venous pressure

ANS: C Arterial blood gas

(ABG) analysis is the most specific information because ventilatory failure causes problems with CO2 retention, and ABGs give information about the PaCO2 and pH. Chest x-ray, oxygen saturation, and central venous pressure monitoring may also be done to help in assessing oxygenation or determining the cause of the patient‗s ventilatory failure.

2. A patient who was admitted with a pulmonary embolism has a change in oxygen saturation (SpO2) from 94% to 88%. Which action would the nurse take?

a. Suction the patients oropharynx.

b. Increase the prescribed O2 flowrate.

c. Teach the patient to cough and deep breathe.

d. Help the patient to sit in an upright position.

ANS: B Increase the prescribed O2 flowrate.

Increasing O2 flowrate will usually improve O2 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.

3. A patient with respiratory failure is increasingly lethargic, with a respiratory rate of 6 breaths/min and an oxygen saturation (SpO2) of 78%. Which intervention would the nurse anticipate?

a. Administration of 100% O2 by non-rebreather mask

b. Endotracheal intubation and positive pressure ventilation

c. Insertion of a mini-tracheostomy with frequent suctioning

d. Initiation of continuous positive pressure ventilation (CPAP)

ANS: B Endotracheal intubation and positive pressure ventilation

The patient‗s lethargy, low respiratory rate, and SpO2 indicate the need for mechanical

ventilation with ventilator-controlled respiratory rate. Giving high-flow O2 will not be helpful

because the patient‗s respiratory rate is so low. Insertion of a mini-tracheostomy will promote

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.

4. The oxygen saturation (SpO2) for a patient with left lower lobe pneumonia is 90%. The patient has wheezes and a weak cough effort. Which action would the nurse take?

a. Position the patient on the left side.

b. Assist the patient with staged coughing.

c. Place a humidifier in the patients room.

d. Schedule a 4-hour rest period for the patient.

ANS: B Assist the patient with staged coughing

The patient‗s assessment indicates that assisted coughing is needed to help remove secretions,

which will improve oxygenation. A 4-hour rest period at this time may allow the O2 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.

5. A nurse is caring for a patient with right lower lobe pneumonia who is obese. Which position will provide the best gas exchange?

a. On the left side

b. On the right side

c. In the tripod position

d. In the high-Fowler‗s position

ANS: A On the left side

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.

6. The nurse is admitting a patient with possible respiratory failure and a high PaCO2. Which assessment information would the nurse immediately report to the health care provider?

a. The patient appears somnolent.

b. The patient reports feeling weak.

c. The patient‗s blood pressure is 164/98.

d. The patient‗s oxygen saturation is 90%.

ANS: A The patient appears somnolent.

Increasing somnolence will decrease the patient‗s respiratory rate and effort and further

increase the PaCO2. 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.

7. A patient with acute respiratory distress syndrome (ARDS) and acute kidney injury has several drugs prescribed. Which drug would the nurse discuss with the health care provider before giving?

a. Vancomycin (Vancocin)

b. Pantoprazole (Protonix)

c. Sucralfate (Carafate)

d. Methylprednisolone (Solu-Medrol)

ANS: A Vancomycin (Vancocin)

Vancomycin is potentially nephrotoxic, and the nurse should clarify the drug and dosage with

the health care provider before administration. The other drugs are appropriate for the patient

with ARDS.

8. A patient develops increasing dyspnea and hypoxemia 2 days after heart surgery. Which procedure would the nurse anticipate assisting with to determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by heart failure?

a. Obtaining a ventilation-perfusion scan

b. Drawing blood for arterial blood gases

c. Positioning the patient for a chest x-ray

d. Inserting a pulmonary artery catheter

ANS: D Inserting a pulmonary artery catheter

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.

9. 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?

a. The patient‗s PaO2 is 50 mm Hg and the SaO2 is 88%.

b. The patient has subcutaneous emphysema on the upper thorax.

c. The patient has bronchial breath sounds in both the lung fields.

d. The patient has a first-degree atrioventricular heart block with a rate of 58

beats/min.

ANS: B The patient has subcutaneous emphysema on the upper thorax.

The subcutaneous emphysema indicates barotrauma caused by positive pressure ventilation

and PEEP. Bradycardia, hypoxemia, and bronchial breath sounds are all concerns that need to

be addressed, but they are not specific indications that PEEP should be reduced.

10. Which statement by the nurse to the patient‗s caregiver about the purpose of positive end-expiratory pressure (PEEP) is accurate?

a. ―PEEP will push more air into the lungs during inhalation.‖

b. ―PEEP prevents the lung air sacs from collapsing during exhalation.‖

c. ―PEEP will prevent lung damage while the patient is on the ventilator.‖

d. ―PEEP allows the breathing machine to deliver 100% O2 to the lungs.‖

ANS: B ―PEEP prevents the lung air sacs from collapsing during exhalation.‖

By preventing alveolar collapse during expiration, PEEP improves gas exchange and

oxygenation. PEEP will not prevent lung damage (e.g., fibrotic changes that occur with

ARDS), push more air into the lungs, or change the fraction of inspired oxygen (FIO2)

delivered to the patient.

11. Prone positioning is being used for a patient with acute respiratory distress syndrome (ARDS). Which information obtained by the nurse indicates that the positioning is effective?

a. The patient‗s PaO2 is 89 mm Hg, and the SaO2 is 91%.

b. Endotracheal suctioning results in clear mucous return.

c. Sputum and blood cultures show no growth after 48 hours.

d. The skin on the patient‗s back is intact and without redness.

ANS: A The patient‗s PaO2 is 89 mm Hg, and the SaO2 is 91%

The purpose of prone positioning is to improve the patient‗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.

12. The nurse assesses vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature of 101.2F, blood pressure of 90/56 mm Hg, pulse of 92 beats/min, and

respirations of 34 breaths/min. Which action would the nurse take next?

a. Give the scheduled IV antibiotic.

b. Give the PRN acetaminophen (Tylenol).

c. Obtain oxygen saturation using pulse oximetry.

d. Notify the health care provider of these findings.

ANS: C Obtain oxygen saturation using pulse oximetry.

The patient‗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 patient. Giving the scheduled

antibiotic and the PRN acetaminophen will also be done, but they are not the highest priority

for a patient who may be developing ARDS.

13. A nurse is caring for a patient who is orally intubated and receiving mechanical ventilation. To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care?

a. Elevate head of bed to 30 to 45 degrees.

b. Give enteral feedings at no more than 10 mL/hr.

c. Suction the endotracheal tube every 2 to 4 hours.

d. Limit the use of positive end-expiratory pressure.

ANS: A Elevate head of bed to 30 to 45 degrees.

Elevation of the head decreases the risk for aspiration. Positive end-expiratory pressure is

frequently needed to improve oxygenation in patients receiving mechanical ventilation.

Suctioning should be done only when the patient assessment indicates that it is necessary.

Enteral feedings should provide adequate calories for the patient‗s high energy needs.

14. A patient admitted with acute respiratory failure is unable to clear thick secretions from the airway. Which nursing intervention would specifically address this patient problem?

a. Encourage use of the incentive spirometer.

b. Offer the patient fluids at frequent intervals.

c. Teach the patient the importance of ambulation.

d. Titrate oxygen level to keep O2 saturation above 93%.

ANS: B Offer the patient fluids at frequent intervals

Thick, viscous secretions are hard to expel. Adequate fluid intake (2 to 3 L/day) keeps

secretions thin and easier to remove, so the best action will be to encourage the patient to

improve oral fluid intake. Patients should be instructed to use the incentive spirometer on a

regular basis (e.g., every hour) to facilitate the clearance of the secretions. The other actions

may be helpful in improving the patient‗s gas exchange, but they do not address the thick

secretions that are causing the poor airway clearance.

15. A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation develops a right pneumothorax. Which collaborative action will the nurse anticipate next?

a. Increase the tidal volume and respiratory rate.

b. Decrease the fraction of inspired oxygen (FIO2).

c. Perform endotracheal suctioning more frequently.

d. Lower the positive end-expiratory pressure (PEEP).

ANS: D Lower the positive end-expiratory pressure (PEEP).

Because barotrauma is associated with high airway pressures, the level of PEEP should be

decreased. The other actions will not decrease the risk for another pneumothorax.

16. After receiving change-of-shift report on a medical unit, which patient would the nurse assess first?

a. A patient with cystic fibrosis who has thick, green-colored sputum

b. A patient with pneumonia who has crackles bilaterally in the lung bases

c. A patient with emphysema who has an oxygen saturation of 90% to 92%

d. A patient with septicemia who has intercostal and suprasternal retractions

ANS: D A patient with septicemia who has intercostal and suprasternal retractions

This patient‗s history of septicemia and labored breathing suggest the onset of ARDS, which

will require rapid interventions such as administration of O2 and use of positive-pressure

ventilation. The other patients should also be assessed, but their assessment data are typical of

their disease processes and do not suggest deterioration in their status.

17. A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department reporting shortness of breath on minimal exertion. Which assessment finding by the nurse would be most important to report to the health care provider?

a. The patient has bibasilar lung crackles.

b. The patient is sitting in the tripod position.

c. The patient‗s respiratory rate is 10 breaths/min.

d. The patient‗s pulse oximetry shows a 91% O2 saturation.

ANS: C The patient‗s respiratory rate is 10 breaths/min.

A drop in respiratory rate in a patient 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. 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 O2 saturation of 91% is common in patients with

COPD and will provide adequate gas exchange and tissue oxygenation.

18. The nurse observes a new onset of agitation and confusion in a patient with chronic obstructive pulmonary disease (COPD). Which action would the nurse take first?

a. Test for facial symmetry.

b. Notify the health care provider.

c. Attempt to calm and reorient the patient.

d. Assess oxygenation using pulse oximetry.

ANS: D Assess oxygenation using pulse oximetry.

Because agitation and confusion are often the initial indicators of hypoxemia, the nurse‗s

initial action should be to assess O2 saturation. The other actions are appropriate, but

assessment of oxygenation takes priority over other assessments and notification of the health

care provider.

19. The nurse is caring for a patient who arrived in the emergency department with acute respiratory distress. Which assessment finding by the nurse requires the most rapid action?

a. The patient‗s PaO2 is 45 mm Hg.

b. The patient‗s PaCO2 is 33 mm Hg.

c. The patient‗s respirations are shallow.

d. The patient‗s respiratory rate is 32 breaths/min.

ANS: A The patient‗s PaO2 is 45 mm Hg.

The PaO2 indicates severe hypoxemia and respiratory failure. Rapid action is needed to

prevent further deterioration of the patient. Although the shallow breathing, rapid respiratory

rate, and low PaCO2 also need to be addressed, the most urgent problem is the patient‗s poor

oxygenation.

20. The nurse is caring for an older patient who was hospitalized 2 days earlier with community-acquired pneumonia. Which assessment information is most important to

communicate to the health care provider?

a. Persistent cough of blood-tinged sputum

b. Scattered crackles in the posterior lung bases

c. Oxygen saturation 90% on 100% O2 by non-rebreather mask

d. Temperature 101.5F (38.6C) after 2 days of IV antibiotics

ANS: C Oxygen saturation 90% on 100% O2 by non-rebreather mask

The patient‗s low SpO2 despite receiving a high fraction of inspired oxygen (FIO2) indicates

the possibility of acute respiratory distress syndrome (ARDS). The patient‗s blood-tinged

sputum and scattered crackles are not unusual in a patient with pneumonia, although they do

need 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 a high O2 flowrate.

21. Which nursing interventions included in the care of a mechanically ventilated patient with acute respiratory failure can the registered nurse (RN) delegate to an experienced licensed practical/vocational nurse (LPN/VN) working in the intensive care unit?

a. Assess breath sounds every hour.

b. Monitor central venous pressures.

c. Place patient in the prone position.

d. Insert an indwelling urinary catheter.

ANS: D Insert an indwelling urinary catheter.

Insertion of indwelling urinary catheters is included in LPN/VN education and scope of

practice and can be safely delegated to an LPN/VN who is experienced in caring for critically

ill patients. Placing a patient who is on a ventilator in the prone position requires multiple staff

and should be supervised by an RN. Assessment of breath sounds and obtaining central

venous pressures require advanced assessment skills and should be done by the RN caring for

a critically ill patient.

22. A nurse is caring for a patient with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation using synchronized intermittent mandatory ventilation (SIMV). The settings include fraction of inspired oxygen (FIO2) of 80%, tidal volume of 450, rate of 16/minute, and positive end-expiratory pressure (PEEP) of 5 cm. Which assessment

finding is most important for the nurse to report to the health care provider?

a. O2 saturation of 99%

b. Heart rate 106 beats/min

c. Crackles audible at lung bases

d. Respiratory rate 22 breaths/min

ANS: A O2 saturation of 99%

The FIO2 of 80% increases the risk for O2 toxicity. Because the patient‗s O2 saturation is 99%,

a decrease in FIO2 could help to avoid toxicity. The other patient data would be typical for a

patient with ARDS and would not be the most important data to report to the health care

provide

23. The nurse is caring for a patient who is intubated and receiving positive pressure ventilation to treat acute respiratory distress syndrome (ARDS). Which finding is most important to report

to the health care provider?

a. Red-brown drainage from nasogastric tube

b. Blood urea nitrogen (BUN) level 32 mg/dL

c. Scattered coarse crackles heard throughout lungs

d. Arterial blood gases: pH of 7.31, PaCO2 of 50, and PaO2 of 68

ANS: A Red-brown drainage from nasogastric tube

The nasogastric drainage indicates possible gastrointestinal bleeding or stress ulcer and should

be reported. The pH and PaCO2 are slightly abnormal, but current guidelines advocating for

permissive hypercapnia indicate that these would not indicate an immediate need for a change

in therapy. The BUN is slightly elevated but does not indicate an immediate need for action.

Adventitious breath sounds are often heard in patients with ARDS.

24. During change-of-shift report on a medical unit, the nurse learns that a patient with aspiration pneumonia who was admitted with respiratory distress has become increasingly agitated. Which action would the nurse take first?

a. Give the prescribed PRN sedative drug.

b. Offer reassurance and reorient the patient.

c. Use pulse oximetry to check the oxygen saturation.

d. Notify the health care provider about the patient‗s status.

ANS: C Use pulse oximetry to check the oxygen saturation.

Agitation may be an early indicator of hypoxemia. The other actions may also be appropriate,

depending on the findings about O2 saturation.

25. The nurse reviews the electronic health record for a patient scheduled for a total hip replacement. Which assessment data shown in the accompanying figure increase the patient‗s risk for respiratory failure after surgery?

History

. Age: 81

. Medical/Surgical history:

Recent 15 lb weight loss,

Knee arthroscopy 3

months ago

Laboratory Data

· Hemoglobin 11.8 g/dL

· Hematocrit 38%

· Albumin 2.7 mg/dL

Physical Assessment

. Lungs clear to auscultation

. Mildly confused:

disoriented to date,

oriented to person and

place

a. Older age and anemia

b. Albumin level and weight loss

c. Recent arthroscopic procedure

d. Confusion and disorientation to time

ANS: B Albumin level and weight loss

The patient‗s recent weight loss and low protein stores indicate possible muscle weakness,

which make it more difficult for an older patient to recover from the effects of general

anesthesia and immobility associated with the hip surgery. The other information will also be

noted by the nurse but does not place the patient at higher risk for respiratory failure.

1. Which actions would the nurse use to reduce a patient‗s risk for ventilator-associated

pneumonia (VAP)? (Select all that apply.) FOUR answers

a. Obtain arterial blood gases daily.

b. Provide a ―sedation holiday‖ daily.

c. Give prescribed pantoprazole (Protonix).

d. Elevate the head of the bed to at least 30 degrees.

e. Provide oral care daily with chlorhexidine (0.12%) solution.

ANS: B, C, D, E

B. Provide a ―sedation holiday‖ daily.

C. Give prescribed pantoprazole (Protonix).

D. Elevate the head of the bed to at least 30 degrees.

E. Provide oral care daily with chlorhexidine (0.12%) solution.

These interventions are part of the ventilator bundle that is recommended to prevent VAP.

Arterial blood gases may be done daily but are not always necessary and do not help prevent

VAP.