ARDS nclex questions

Which S&S distinguish hypoxemia from hypercapnic respiratory failure? SATA

a. Cyanosis

b. Tachypnea

c. Morning headache

d. Paradoxical breathing

e. Use of pursed lip breathing

A, B, D

A: Cynosis is a late sign of hypoxemia

B: Tachypnea is a sign of hypoxemia

D: Paradoxical breathing is a late sign of hypoxmeia

C & E are S&S of Hypercapnia

A nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing ARDS? (SATA)

a. A client who experienced a near drowning

b. A client following coronary artery bypass graft surgery

c. A client who has a hemoglobin of 15.1 mg/dL

d. A client who has dysphagia

E. A client who experienced acute drug toxicity

A: CORRECT - near drowning incident is at risk for developing ARDS due to trauma to lungs and cerebral edema.

B: CORRECT - at risk for developing ARDS due to trauma to chest

C: NO - hemoglobin of 15.1 is within expected range. Client with low hemoglobin as at risk for ARDS

D: CORRECT - difficulty swallowing and risk for aspiration

E: CORRECT - damage to central nervous system

An important consideration in selecting an 02 delivery device for the patient with acute hypoxemic respiratory failure is to

a. Always start with noninvasive positive pressure ventilation

b. Apply a low flow device, such as a nasal cannula or face mask

c. Be able to correct the PaO2 to a normal level as quickly as possible

d. Base the selection on the patients condition and amount of FIO2 needed

D

The most common early manifestations of ARDS that the nurse may see are

a. Dyspnea and tachypnea

b. Cyanosis and apprehension

c. Respiratory distress and frothy sputum

d. Bradycardia and increased work of breathing

A

Interventions used in managing the patient with ARDS includes

SATA

a. IV injection of surfactant

b. Aggressive IV fluid resuscitation

c. Giving adequate analgesia and sedation

d. Elevating the HOB 30-45 degrees when supine

e. Monitoring hemodynamic parameters and daily weights

C, D, E

- keep pt dry

- IV injection - could cause bleeding

WHich intervention is most likely to prevent or limit volutrauma in the pt with ARDS who is mechanically ventilated?

a. Increasing PEEP

b. Increasing the inspiratory flow rate

c. Use of low tidal volume ventilation

d. Suctioning the patient via endotracheal tube hourly

C

- pt with ARDS are ventilated with a low VT of 4-8 ml/Kg

- low VT ventilation has reduced mortality and risk for volutrauma

The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding?

a. Slow, deep respirations

b. Rapid, deep respirations

c. Paradoxical respirations

d. Pain, especially on inspiration

D

Typical signs and symptoms include pain and tenderness that is exacerbated by inspiration, shallow respirations,

A pt is in acute respiratory distress syndrome (ARDS) from sepsis. Which measure would be implemented to maintain cardiac output?

a. Administer IV crystalloid fluids.

b. Place the patient on a strict fluid restriction.

c. Position the patient in Trendelenburg position.

d. Perform chest physiotherapy and assist with staged coughing.

A

Low cardiac output may necessitate crystalloid fluids in addition to lowering positive end-expiratory pressure (PEEP) or giving inotropes. The Trendelenburg position is not recommended to treat hypotension. Chest physiotherapy is unlikely to relieve decreased cardiac output. Fluid restriction would be an inappropriate intervention.

A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest?

a. Cyanosis

b. Hypotension

c. Paradoxical chest movement ebt

d. Dyspnea, especially on expiration

C

Flail chest results from multiple rib fractures. This results in a 'floating' section of ribs. This section is unattached to rest of bony rib cage, and results in paradoxical chest movement. Force of inspiration pulls fractured segment inwards, while rest of body expands.

The pt with pulmonary fibrosis has hypoxemia during exercise but not at rest. To plan patient care, the nurse identifies the patient is experiencing which physiologic mechanism of respiratory failure?

a. Diffusion limitation

b. Intrapulmonary shunt

c. Alveolar hypoventilation

d. Ventilation-perfusion mismatch

A

pt with pulmonary fibrosis has a thickened alveolar-capillary interface that slows gas transport, so hypoxemia is more likely during exercise than at rest. Intrapulmonary shunt occurs when alveoli fill with fluid (e.g., acute respiratory distress syndrome, pneumonia). Alveolar hypoventilation occurs when there is a generalized decrease in ventilation (e.g., restrictive lung disease, central nervous system diseases, neuromuscular diseases). Ventilation-perfusion mismatch occurs when the amount of air does not match the amount of blood that the lung receives (e.g., chronic obstructive pulmonary disease, pulmonary embolus).

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign if ARDS?

a. Bilateral wheezes

b. Inspiratory crackles

c. Intercostal retraction

d. Increased respiratory rate

D

Increased respiratory rate is earliest sign of ARDS. Can begin from 1-96 hours after initial insult to body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse course crackles.

Normal PAWP range

6-12 mmHg

What is PAWP?

1. a measurement of pulmonary capillary pressure

2. reflects left ventricular end-diastolic pressure under normal conditions

normal cardiac index

2.5-4 L/min/m2

What is cardiac index?

cardiac output divided by body surface area

- assessment of the cardiac output value based on the patient's size

A pt with acute respiratory distress syndrome (ARDS) is on positive pressure ventilation (PPV). The patient's cardiac index is 1.4 L/min and pulmonary artery wedge pressure is 8 mm Hg. What order by the provider would the nurse to QUESTION?

A. Increase PEEP from 10 to 15 cm H2O.

B. Start a dobutamine infusion at 3 mcg/kg/min.

C. Give 1 unit of packed RBCs over the next 2 hours.

D. Change the maintenance IV rate from 75 to 125 mL/hr.

A

Patients on PPV and PEEP often have decreased cardiac output (CO) and cardiac index (CI). High levels of PEEP increase intrathoracic pressure and cause decreased venous return which results in decreased CO. Interventions to improve CO include lowering the PEEP, giving crystalloid fluids or colloid solutions, and use of inotropic drugs (e.g., dobutamine, dopamine). Packed red blood cells may also be administered to improve CO and oxygenation if the hemoglobin is less than 9 or 10 mg/dL.

When caring for older adult pts with respiratory failure, the nurse will add which intervention to individualize care?

a. Assess frequently for manifestations of delirium.

b. Position the patient in the supine position primarily.

c. Provide early endotracheal intubation to reduce complications.

d. Delay activity and ambulation to provide additional healing time.

A

Older adult patients are more predisposed to delirium and health care-associated infections. Older adult patients are not required to remain in a supine position only and should increase activity as soon as stability is determined. Endotracheal intubation is not provided early, and noninvasive positive pressure ventilation may be considered as an alternative. The nurse should consider that the aging process leads to decreased lung elastic recoil, weakened lung muscles and reduced gas exchange, which may make the patient difficult to wean from the ventilator.

The nurse is admitting a pt with asthma in acute respiratory distress. The nurse auscultates the pt's lungs and notes cessation of the inspiratory wheezing. The pt has not yet received any medication. What should this finding suggest to the nurse?

a. Spontaneous resolution of the acute asthma attack

b. An acute development of bilateral pleural effusions

c. Airway constriction requiring immediate interventions

d. Overworked intercostal muscles resulting in poor air exchange

C

When a pt in respiratory distress has inspiratory wheezing and then it ceases, it is an indication of airway obstruction. This finding requires emergency action to restore airway patency.

Which pt would most benefit from noninvasive positive pressure ventilation (NIPPV) to promote oxygenation?

A. A pt whose cardiac output and blood pressure are unstable.

B. A pt with cystic fibrosis who is currently producing copious secretions.

C. A pt with respiratory failure due to a head injury with loss of consciousness.

D. A pr who has respiratory failure because of the progression of myasthenia gravis.

D

NIPPV such as continuous positive airway pressure (CPAP) is most effective in treating patients with respiratory failure resulting from chest wall and neuromuscular disease. It is not recommended in patients who are experiencing hemodynamic instability, decreased level of consciousness, or excessive secretions.

The nurse is caring for a pt who has developed acute respiratory failure. Which medication is used to decrease patient pulmonary congestion and agitation?

a. Morphine

b. Albuterol

c. Azithromycin

d. Methylprednisolone

A

For pt with acute respiratory failure related to the heart, morphine is used to decrease pulmonary congestion as well as anxiety, agitation, and pain. Albuterol is used to reduce bronchospasm. Azithromycin is used for pulmonary infections. Methylprednisolone is used to reduce airway inflammation and edema.

Arterial blood gas results are reported to the nurse for a patient admitted with pneumonia: pH 7.31, PaCO2 49 mm Hg, HCO3 26 mEq/L, and PaO2 52 mm Hg. What order should the nurse complete first?

a. Administer albuterol inhaler PRN.

b. Start oxygen at 2 L/min by nasal cannula.

c. Increase fluid intake to 2500 mL per 24 hours.

d. Perform chest physical therapy 4 times per day.

B

The arterial blood gas results show the patient is in uncompensated respiratory acidosis with moderate hypoxemia. Oxygen therapy is indicated to correct hypoxemia secondary to V/Q mismatch. Supplemental oxygen should be initiated at 1 to 3 L/min by nasal cannula, or 24% to 32% by simple face mask or Venturi mask to improve the PaO2. Albuterol would be given next if needed for bronchodilation. Hydration is indicated for thick secretions, and chest physical therapy is indicated for patients with 30 mL or more of sputum production per day.

The nurse is caring for a pt who is admitted with a barbiturate overdose. The pt is comatose with a BP of 90/60 mm Hg, apical pulse of 110 beats/min, and respiratory rate of 8 breaths/min. Based on the initial assessment findings, the nurse recognizes that the pt is at risk for which type of respiratory failure?

a. Hypoxemic respiratory failure related to shunting of blood

b. Hypoxemic respiratory failure because of diffusion limitation

C. Hypercapnic respiratory failure related to alveolar hypoventilation

D. Hypercapnic respiratory failure because of increased airway resistance

C

The pt's respiratory rate is decreased because of barbiturate overdose, which caused respiratory depression. The patient is at risk for hypercapnic respiratory failure due to an obtunded airway causing decreased respiratory rate and thus decreased CO2 elimination. Barbiturate overdose does not lead to shunting of blood, diffusion limitations, or increased airway resistance.

The nurse is caring for a pt with multiple musculoskeletal injuries who has developed acute respiratory distress syndrome (ARDS). Which intervention should the nurse initiate to prevent stress ulcers?

a. Observe stools for frank bleeding and occult blood.

b. Maintain head of the bed elevation at 30 to 45 degrees.

c. Begin enteral feedings as soon as bowel sounds are present.

d. Administer prescribed lorazepam (Ativan) to reduce anxiety.

C

Stress ulcers prevention includes early initiation of enteral nutrition to protect the gastrointestinal (GI) tract from mucosal damage. Monitoring for GI bleeding does not prevent stress ulcers. Ventilator-associated pneumonia related to aspiration is prevented by elevation of the head of bed to 30 to 45 degrees Stress ulcers are not caused by anxiety. Stress ulcers are related to GI ischemia from hypotension, shock, and acidosis.

A pt with aspiration pneumonia develops severe respiratory distress. The PaO2 is 42 mmHg and FIO2 is 80%. Which intervention should the nurse complete first?

A. Stat portable chest radiography.

B. Give lorazepam (Ativan) 1 mg IV push.

C. Place the patient in a prone position on a rotational bed.

D. Position the patient with arms supported away from the chest.

D

The nurse will first position the pt to facilitate ventilation. Additional oxygen support may be necessary. Refractory hypoxemia indicates the patient is not demonstrating acute lung injury but has now developed acute respiratory distress syndrome (ARDS). If the PaO2 is 42 mm Hg on 80% FIO2 (fraction of inspired oxygen; room air is 21% FIO2), then the PaO2/FIO2 ratio is 52.5, indicating ARDS (PaO2/FIO2 ratio < 200). Stat portable chest radiography may show worsening infiltrates or "white lung." A rotational bed placing the patient in prone position would be a strategy to use for select patients with ARDS. Lorazepam (Ativan) 1 mg may be harmful to this patient's oxygenation status. Further assessment would be needed to determine safety.

When caring for a pt with acute respiratory distress syndrome (ARDS), which finding indicates therapy is appropriate?

A. Arterial pH is 7.32.

B. PaO2 is greater than or equal to 60 mm Hg.

C. PEEP increased to 20 cm H2O caused BP to fall to 80/40.

D. No change in PaO2 when patient is turned from supine to prone position.

B

The overall goal in caring for the pt with ARDS is for the PaO2 to be greater than or equal to 60 mm Hg with adequate lung ventilation to maintain a normal pH of 7.35 to 7.45. PEEP is usually increased for ARDS patients, but a dramatic reduction in BP indicates a complication of decreased cardiac output. A positive occurrence is a marked improvement in PaO2 from perfusion better matching ventilation when the anterior air-filled, nonatelectatic alveoli become dependent in the prone position.

The nurse is providing care for an older adult pt who has a low partial pressure of oxygen in arterial blood (PaO2) due to worsening left-sided pneumonia. Which intervention should the nurse use to help the patient mobilize his secretions?

a. Augmented coughing or huff coughing

b. Positioning the patient side-lying on his left side

c. Frequent and aggressive nasopharyngeal suctioning

d. Application of noninvasive positive pressure ventilation

A

Augmented coughing and huff coughing techniques may aid the patient in the mobilization of secretions. If positioned side-lying, the patient should be positioned on his right side (good lung down) for improved perfusion and ventilation. Suctioning may be indicated but should always be performed cautiously because of the risk of hypoxia. NIPPV is inappropriate in the treatment of patients with excessive secretions.

The nurse is caring for a pt with multiple fractured ribs from a motor vehicle crash. Which assessment findings would be early indications that the patient is developing respiratory failure?

A. Tachycardia and pursed lip breathing

b. Kussmaul respirations and hypotension

c. Frequent position changes and agitation

d. Cyanosis and increased capillary refill time

C

A change in mental status is an early indication of respiratory failure. The brain is sensitive to variations in oxygenation, arterial carbon dioxide levels, and acid-base balance. Restlessness, confusion, agitation, and combative behavior suggest inadequate oxygen delivery to the brain.

A nurse is caring for a client who has a trache and is receiving mechanical ventilation. When the low-pressure alarm on the ventilator sounds, it indicates which of the following to the nurse?

a. Excessive airway secretions

b. A leak within the ventilators circuitry

c. Decreased lung compliance

d. The client coughing or attempting to talk

B

THe low-pressure alarm indicates that wither the ventilator tubing has come apart or the tubing detached front the client

A nurse on a medical unit is caring for a client who aspirated gastric contents prior to admission. The nurse administers 100% O2 by nonrebreather mask after the client reports severe dyspnea. Which of the following findings is a clinical manifestations of acute respiratory distress syndrome (ARDS)?

a. Tympanic temperature 38 (100.4)

b. PaO2 50mmHg

c. Rhonchi

D. Hypopnea

B

Ards manifestations includes low PaO2 (

A nurse in an acute care facility is preparing to admit a client who has myasthenia gravis. Which of the following supplies should the nurse place at the client's bedside?

a. Metered dose inhaler

b. Continuous passive motion machine

c. Oral nasal suction equipment

d. External defribrillator pads

C

risk of aspiration due to progressive weakness of the oropharyngeal muscles.

A nurse in the ED is assessing a client who was in a motor vehicle crash. Findings include absent breath sounds in left lower lobe with dyspnea, BP 118/68 mmHg, HR 124/min, RR 38/min, temp 38.6 (101.4), and SaO2 92% on room air. Which of the following actions should the nurse take FIRST?

a. Obtain chest X-ray

b. Prepare for chest tube insertion

c. Administer oxygen via a high flow mask

D. Initiate IV access

C

A nurse is orienting a new nurse on the purpose of administering vecuronium to a client who has ARDS. Which of the flowing statements by new nurse indicates understanding of the teaching?

a. "This medication is given to treat infection"

b. "This medication is given to facilitate ventilation"

c. "This medication is given to decrease inflammation"

d. "This mediation is given to reduce anxiety"

B

vecuronium is a neuromuscular blocking agent giving to facilitate ventilation and decrease oxygen consumption.

A nurse is caring for client who is receiving vercuronium during mechanical ventilation. Which of the following medications should the nurse anticipate administering with this medication? (SATA)

a. Fentanyl

b. Furosemide

c. Misazolam

d. Famotidine

e. Dexamethasone

A. CORRECT - pain med administer to pt when neuromuscular blocking agen, such as vecuronium is asminstered

C. CORRECT - sedative medication administered to clients