Medical-Surgical Nursing Assessment and Management of Clinical Problems 9e Chapter 68

Chapter 68: Nursing Management: Respiratory Failure and Acute Respiratory Distress
Syndrome
Test Bank
MULTIPLE CHOICE
1. To evaluate the effectiveness of ordered interventions for a patient with ventilatory failure,
which diagnostic test will be most useful to the nurse?
a.Chest x-ray
b.Oxygen saturation
c.Arterial blood gas analysis
d.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 patients ventilatory failure.
DIF: Cognitive Level: Apply (application) REF: 1661

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity
2. While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes
a change in the patients oxygen saturation (SpO2) from 94% to 88%. Which action should the
nurse take next?
a. Increase the oxygen flow rate.
b. Suction the patients oropharynx.
c. Instruct the patient to cough and deep breathe.
d. 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.

TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
3. 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?
a. Administration of 100% oxygen 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
The patients 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 patients respiratory rate is so low. Insertion of a mini-tracheostomy
will facilitate removal of secretions, but it will not improve the patients 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
4. 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?
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 2-hour rest period for the patient.
ANS: B
The patients 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
5. A nurse is caring for an obese patient with right lower lobe pneumonia. Which position will be
best to improve gas exchange?
a. On the left side
b. On the right side
c. In the tripod position
d. In the high-Fowlers 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 patients abdomen will limit
respiratory excursion when sitting in the high-Fowlers or tripod positions.

6. When admitting a patient with possible respiratory failure with a high PaCO2, which
assessment information should be immediately reported to the health care provider?
a. The patient is somnolent.
b. The patient complains of weakness.
c. The patients blood pressure is 164/98.
d. The patients oxygen saturation is 90%.
ANS: A
Increasing somnolence will decrease the patients 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.

7. 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?
a. Pantoprazole (Protonix) 40 mg IV
b. Gentamicin (Garamycin) 60 mg IV
c. Sucralfate (Carafate) 1 g per nasogastric tube
d. 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.

8. 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
a. obtaining a ventilation-perfusion scan.
b. drawing blood for arterial blood gases.
c. insertion of a pulmonary artery catheter.
d. 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.

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 patients 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.
ANS: B
The subcutaneous emphysema indicates barotrauma caused by positive pressure ventilation
and PEEP. Bradycardia, hypoxemia, and bronchial breath sounds are all concerns and will
need to be addressed, but they are not specific indications that PEEP should be reduced.

10. Which statement by the nurse when explaining the purpose of positive end-expiratory
pressure (PEEP) to the family members of a patient with ARDS 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% oxygen to the lungs.
ANS: B
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.
DIF: Cognitive Level: Understand (comprehension) REF: 1669

11. A patient with acute respiratory distress syndrome (ARDS) is placed in the prone position.
When prone positioning is used, which information obtained by the nurse indicates that the
positioning is effective?
a. The patients 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 patients back is intact and without redness.
ANS: A
The purpose of prone positioning is to improve the patients oxygenation as indicated by the
PaO2 and SaO2. The other information will be collected but does not indicate whether prone
positioning has been effective.

TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
12. The nurse documents the vital signs for a patient admitted 2 days ago with gram-negative
sepsis: temperature 101.2 F, blood pressure 90/56 mm Hg, pulse 92, respirations 34. Which
action should 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 the patients vital signs.
ANS: C
The patients 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. Suction the endotracheal tube every 2 to 4 hours.
c. Limit the use of positive end-expiratory pressure.
d. Give enteral feedings at no more than 10 mL/hr.
ANS: A
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 patients high energy needs.

14. A patient admitted with acute respiratory failure has a nursing diagnosis of ineffective airway
clearance related to thick, secretions. Which action is a priority for the nurse to include in the
plan of care?
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 >93%.
ANS: B
Because the reason for the poor airway clearance is the thick secretions, 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) in order to facilitate the clearance of
the secretions. The other actions may also be helpful in improving the patients gas exchange,
but they do not address the thick secretions that are causing the poor airway clearance.

OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning
15. A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving
mechanical ventilation develops a right pneumothorax. Which action will the nurse anticipate
taking next?
a. Increase the tidal volume and respiratory rate.
b. Increase the fraction of inspired oxygen (FIO2).
c. Perform endotracheal suctioning more frequently.
d. Lower the positive end-expiratory pressure (PEEP).
ANS: D
Because barotrauma is associated with high airway pressures, the level of PEEP should be
decreased. The other actions will not decrease the risk for pneumothorax.

16. After receiving change-of-shift report on a medical unit, which patient should 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
This patients history of septicemia and labored breathing suggest the onset of ARDS, which
will require rapid interventions such as administration of oxygen and use of positive pressure
ventilation. The other patients should also be assessed as quickly as possible, but their
assessment data are typical of their disease processes and do not suggest deterioration in their
status.
DIF: Cognitive Level: Analyze (analysis) REF: 1659 | 1667

OBJ: Special Questions: Prioritization; Multiple Patients
TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment
17. A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency
department complaining of shortness of breath and dyspnea on minimal exertion. Which
assessment finding by the nurse is 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 patients respirations have decreased from 30 to 10 breaths/minute.
d. The patients pulse oximetry indicates an O2 saturation of 91%.
ANS: 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 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 oxygen saturation of 91% is common in patients
with COPD and will provide adequate gas exchange and tissue oxygenation.

OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment
18. When assessing a patient with chronic obstructive pulmonary disease (COPD), the nurse finds
a new onset of agitation and confusion. Which action should the nurse take first?
a. Notify the health care provider.
b. Check pupils for reaction to light.
c. Attempt to calm and reorient the patient.
d. Assess oxygenation using pulse oximetry.
ANS: D
Because agitation and confusion are frequently the initial indicators of hypoxemia, the nurses
initial action should be to assess oxygen saturation. The other actions are also appropriate, but
assessment of oxygenation takes priority over other assessments and notification of the health
care provider.

19. The nurse is caring for a 33-year-old patient who arrived in the emergency department with
acute respiratory distress. Which assessment finding by the nurse requires the most rapid
action?
a. The patients PaO2 is 45 mm Hg.
b. The patients PaCO2 is 33 mm Hg.
c. The patients respirations are shallow.
d. The patients respiratory rate is 32 breaths/minute.
ANS: A
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 patients poor
oxygenation.

20. The nurse is caring for a 78-year-old 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. Scattered crackles bilaterally in the posterior lung bases.
b. Persistent cough that is productive of blood-tinged sputum.
c. Temperature of 101.5 F (38.6 C) after 2 days of IV antibiotic therapy.
d. Decreased oxygen saturation to 90% with 100% O2 by non-rebreather mask.
ANS: D
The patients low SpO2 despite receiving a high fraction of inspired oxygen (FIO2) indicates
the possibility of acute respiratory distress syndrome (ARDS). The patients blood-tinged
sputum and scattered crackles are not unusual in a patient with pneumonia, although they do
require 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 an increase in O2 flow rate.

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/LVN) 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
Insertion of indwelling urinary catheters is included in LPN/LVN education and scope of
practice and can be safely delegated to an LPN/LVN 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.

OBJ: Special Questions: Delegation TOP: Nursing Process: Planning
MSC: NCLEX: Safe and Effective Care Environment
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) 80%, tidal volume 450, rate
16/minute, and positive end-expiratory pressure (PEEP) 5 cm. Which assessment finding is
most important for the nurse to report to the health care provider?
a. Oxygen saturation 99%
b. Respiratory rate 22 breaths/minute
c. Crackles audible at lung bases
d. Heart rate 106 beats/minute
ANS: A
The FIO2 of 80% increases the risk for oxygen toxicity. Because the patients O2 saturation is
99%, a decrease in FIO2 is indicated to avoid toxicity. The other patient data would be typical
for a patient with ARDS and would not need to be urgently reported to the health care
provider.
DIF: Cognitive Level: Analyze (analysis) REF: 1669

23. Which information about a patient who is receiving cisatracurium (Nimbex) to prevent
asynchronous breathing with the positive pressure ventilator requires immediate action by the
nurse?
a. Only continuous IV opioids have been ordered.
b. The patient does not respond to verbal stimulation.
c. There is no cough or gag when the patient is suctioned.
d. The patients oxygen saturation fluctuates between 90% to 93%.
ANS: A
Because neuromuscular blockade is extremely anxiety provoking, it is essential that patients
who are receiving neuromuscular blockade receive concurrent sedation and analgesia.
Absence of response to stimuli is expected in patients receiving neuromuscular blockade. The
oxygen saturation is adequate.

24. 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. Blood urea nitrogen (BUN) level 32 mg/dL
b. Red-brown drainage from orogastric tube
c. Scattered coarse crackles heard throughout lungs
d. Arterial blood gases: pH 7.31, PaCO2 50, PaO2 68
ANS: B
The nasogastric drainage indicates possible gastrointestinal bleeding and/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 commonly heard in patients with ARDS.

25. 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 should 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 patients status.
ANS: C
Agitation may be an early indicator of hypoxemia. The other actions may also be appropriate,
depending on the findings about oxygen saturation.

26. The nurse reviews the electronic medical record for a patient scheduled for a total hip
replacement. Which assessment data shown in the accompanying figure increase the patients
risk for respiratory complications after surgery?
a. Albumin level and recent weight loss
b. Mild confusion and recent weight loss
c. Age and recent arthroscopic procedure.
d. Anemia and recent arthroscopic procedure
ANS: A
The patients 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.

MULTIPLE RESPONSE
1. Which actions should the nurse initiate to reduce the risk for ventilator-associated pneumonia
(VAP) (select all that apply)?
a. Obtain arterial blood gases daily.
b. Provide a sedation holiday daily.
c. Elevate the head of the bed to at least 30.
d. Give prescribed pantoprazole (Protonix).
e. Provide oral care with chlorhexidine (0.12%) solution daily.
ANS: B, C, D, E
All of 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.


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Chapter 68: Nursing Management: Respiratory Failure and Acute Respiratory Distress

DIF: Cognitive Level: Apply (application) REF: 1661

DIF: Cognitive Level: Apply (application) REF: 1656

DIF: Cognitive Level: Apply (application) REF: 1658 | 1662

DIF: Cognitive Level: Apply (application) REF: 1661-1662

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DIF: Cognitive Level: Apply (application) REF: 1669

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DIF: Cognitive Level: Apply (application) REF: 1668-1669

DIF: Cognitive Level: Understand (comprehension) REF: 1669

DIF: Cognitive Level: Apply (application) REF: 1670

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DIF: Cognitive Level: Analyze (analysis) REF: 1659 | 1667

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DIF: Cognitive Level: Apply (application) REF: 1658 | 1665

DIF: Cognitive Level: Apply (application) REF: 1665-1670

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DIF: Cognitive Level: Analyze (analysis) REF: 1669

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DIF: Cognitive Level: Apply (application) REF: 1663

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DIF: Cognitive Level: Apply (application) REF: 1668

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