Acute Resp Distress Syndrome (ARDS) Answer Key Part 2

21. When the nurse is caring for an obese patient with left lower-lobe pneumonia, gas exchange will be best when the patient is positioned a. on the left side. b. on the right side. c. in the high-Fowler's position. d. in the tripod position 22. When admitting a patient in possible respiratory failure with a high PaCO2, which assessment information will be of most concern to the nurse? a. The patient is somnolent. b. The patient's SpO2 is 90%. c. The patient complains of weakness. d. The patient's blood pressure is 162/94. 23. The nurse is caring for a patient who was hospitalized 2 days earlier with aspiration pneumonia. Which assessment information is most important to communicate to the health care provider? a. The patient has a cough that is productive of blood-tinged sputum. b. The patient has scattered crackles throughout the posterior lung bases. c. The patient's temperature is 101.5° F after 2 days of IV antibiotic therapy. d. The patient's SpO2 has dropped to 90%, although the O2 flow rate has been increased 24. When caring for a patient who developed acute respiratory distress syndrome (ARDS) as a result of a urinary tract infection (UTI), the nurse is asked by the patient's family how a urinary tract infection could cause lung damage. Which response by the nurse is appropriate? a. "The infection spread through the circulation from the urinary tract to the lungs." b. "The urinary tract infection produced toxins that damaged the lungs." c. "The infection caused generalized inflammation that damaged the lungs." d. "The fever associated with the infection led to scar tissue formation in the lungs." 25. All the following medications are ordered for a mechanically ventilated patient with acute respiratory distress syndrome (ARDS) and acute renal failure. Which medication should the nurse discuss with the health care provider before administration? a. IV ranitidine (Zantac) 50 mg IV b. sucralfate (Carafate) 1 g per nasogastric tube c. IV gentamicin (Garamycin) 60 mg d. IV methylprednisolone (Solu-Medrol) 40 mg 26. After prolonged cardiopulmonary bypass, a patient develops increasing shortness of breath and hypoxemia. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by left ventricular failure, the nurse will anticipate assisting with a. positioning the patient for a chest radiograph. b. drawing blood for arterial blood gases. c. obtaining a ventilation-perfusion scan. d. inserting a pulmonary artery catheter. 27. Which information obtained by the nurse when assessing a patient with acute respiratory distress syndrome (ARDS) who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP) indicates a complication of ventilator therapy is occurring? a. The patient has subcutaneous emphysema b. The patient has a sinus bradycardia, rate 52 c. The patient's PaO2 is 50 mm Hg and the SaO2 is 88% d. The patient has bronchial breath sounds in both the lung fields. 28. Which statement by the nurse when explaining the purpose of positive endexpiratory pressure (PEEP) to the family members of a patient with ARDS is correct? a. "PEEP will prevent fibrosis of the lung from occurring” b. "PEEP will push more air into the lungs during inhalation” c. "PEEP allows the ventilator to deliver 100% oxygen to the lungs” d. "PEEP prevents the lung air sacs from collapsing during exhalation” 29. When prone positioning is used in the care of a patient with acute respiratory distress syndrome (ARDS), which information obtained by the nurse indicates that the positioning is effective? a. The skin on the patient's back is intact and without redness b. Sputum and blood cultures show no growth after 24 hours c. The patient's PaO2 is 90 mm Hg, and the SaO2 is 92% d. Endotracheal suctioning results in minimal mucous return 30. A patient with acute respiratory distress syndrome (ARDS) has progressed to the fibrotic phase. The patient's family members are anxious about the patient's condition and are continuously present at the hospital. In addressing the family's concerns, it is important for the nurse to a. support the family and help them understand the realistic expectation that the patient's chance for survival is poor b. inform the family that home health nurses will be able to help them maintain the mechanical ventilation at home after patient discharge c. refer the family to social support services and case management to plan for transfer of the patient to a long-term care facility d. d. provide hope and encouragement to the family because the patient's disease process has started to resolve ANSWERS 21-30: 21. B Rationale: 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. 22. A Rationale: 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. 23. D Rationale: The patient's dropping SpO2 despite having an increase in 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 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. 24. C Rationale: The pathophysiologic changes that occur in ARDS are thought to be caused by inflammatory and immune reactions that lead to changes at the alveolar-capillary membrane. ARDS is not directly caused by infection, toxins, or fever. 25. C Rationale: 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. 26. D Rationale: Pulmonary artery wedge pressure will remain at normal levels 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. 27. A Rationale: Complications of positive-pressure ventilation (PPV) and PEEP include subcutaneous emphysema. Bradycardia, hypoxemia, and bronchial breath sounds are all concerns, but they are not caused by PPV and PEEP. 28. D Rationale: By preventing alveolar collapse during expiration, PEEP improves gas exchange and oxygenation. PEEP will not prevent the fibrotic changes that occur with ARDS, push more air into the lungs, or change the fraction of inspired oxygen (FIO2) delivered to the patient. 29. C Rationale: 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. 30. A Rationale: The chance for survival is poor when the patient progresses to the fibrotic stage because permanent damage to the alveoli has occurred. Because of continued severe hypoxemia, the patient is not a candidate for home health or long-term care. The fibrotic stage indicates a poor patient prognosis, not the resolution of the ARDS process. 31. The nurse obtains the vital signs for a patient admitted 2 days ago with gramnegative sepsis: temperature 101.2° F, blood pressure 90/56 mm Hg, pulse 92, respirations 34. Which action should the nurse take next? a. Notify the health care provider of the patient's vital signs. b. Obtain oxygen saturation using pulse oximetry. c. Document the vital signs and continue to monitor. d. Administer PRN acetaminophen (Tylenol) 650 mg. 32. Which intervention is key to preventing ventilator-associated pneumonia as a complication in a patient with acute respiratory distress syndrome (ARDS)? A. Scheduled prophylactic nasopharyngeal suctioning B. Instilling normal saline down the endotracheal tube to loosen secretions C. Providing frequent mouth care and oral hygiene D. Using high tidal volumes on the ventilator 33. What are the most common early clinical manifestations of ARDS? A. Dyspnea and tachypnea B. Cyanosis and apprehension C. Hypotension and tachycardia D. Respiratory distress and frothy sputum 34. Which intervention is most likely to prevent or limit barotrauma in the patient with ARDS who is mechanically ventilated? A. Decreasing PEEP B. Use of permissive hypercapnia C. Increasing the tidal volume D. Use of positive pressure ventilation 35. A nurse walks in to a client who is in respiratory distress. The client has tracheal deviation to the right side. The nurse knows to prepare for which of the following emergent procedures? a. Chest tube insertion on the right side b. Chest tube insertion on the left side c. Intubation d. Tracheostomy 36. A 26-year-old patient is admitted to the hospital in severe respiratory distress. His oxygen saturations are 80% despite supplemental oxygen provided by facemask. The physician decides to intubate the patient to help with his breathing oxygenation. Which medication would the nurse most likely administer when assisting with intubation? a. Midazolam (Versed) b. Zolpidem (Ambien) c. Phentermine (Adipex-P) d. Modafinil (Provigil) 37. A nurse must position the patient prone after his diagnosis of acute respiratory distress syndrome. Which of the following is a benefit of using this position? Select all that apply. 1. Decreased atelectasis 2. Reduced need for endotracheal intubation 3. Mobilization of secretions 4. Decreased fluid accumulation 5. Increased response to corticosteroid therapy 38. A nurse is planning care for a patient with ARDS who will receive an oropharyngeal airway after his airway became obstructed. The nurse knows that which of the following is true about this procedure? Select all the apply. a. It is better tolerated than a nasopharyngeal airway b. The client must have a gag reflex c. Oral care must be given every 8 hours d. For the client who has general anesthesia e. For the client who has a head injury 39. In ARDS, initially the patient experiences respiratory alkalosis due to the increased CO2 being expelled out from the increased respiratory rate. The nurse knows that which of the following factors contributes to the later signs of respiratory acidosis? a. Alveoli is inactivated, which causes pulmonary edema b. Hyaline membranes form which does not allow CO2 escape, increasing the CO2 concentration in the blood c. Refractory hypoxemia, which impairs gas exchange with CO2 d. The normal hydrostatic pressure that pushes fluid out of the capillaries interact with CO2 thus rising its levels 40. The oxygen delivery system chosen for the patient in acute respiratory failure should A. always be a low-flow device, such as a nasal cannula. B. correct the PaO2 to a normal level as quickly as possible. C. administer positive-pressure ventilation to prevent CO2 narcosis. D. maintain the PaO2 at ≥60 mm Hg at the lowest O2 concentration possible ANSWERS 31-40: 31. B Rationale: 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. Documentation and continued monitoring of the vital signs are needed but do not constitute an adequate response to the patient situation. Tylenol administration is appropriate but not the highest priority for this patient. 32. C Rationale: 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. 33. A Rationale: The initial manifestations of ARDS are often subtle. At the time of the initial injury and for several hours up to 2 days afterward, the patient may not experience respiratory symptoms, or the patient may exhibit only dyspnea, tachypnea, cough, and restlessness. 34. B Rationale: To avoid barotrauma and minimize risks associated with elevated plateau and peak inspiratory pressures, the patient with ARDS is often ventilated with smaller tidal volumes and various amounts of PEEP to minimize oxygen requirements and intrathoracic pressures. One result of this protocol is an elevation in PaCO2, also called permissive hypercapnia because the PaCO2 is allowed to rise above normal limits. 35. B Rationale:Tracheal deviation indicates a pneumothorax, the direction of the deviation indicates the side the pneumothorax is on. If the trachea is deviating to the right, then the pneumo is on the left. The treatment for this is a chest tube on the side of the deflated lung. 36. A Rationale:Intubation is most often performed by inserting a tube into the mouth and passing it into the trachea in order to provide help and support for a patients breathing. Most registered nurses do not perform endotracheal intubation, but they may assist the physician with placing the tube. The nurse may give medications to sedate the patient during the procedure, since it can be traumatic for the patient. Some medications given for sedation include midazolam, fentanyl, and etomidate. 37. 1,3,4 Rationale:Prone positioning, or placing the patient face down with the head turned to the side, helps with pulmonary function in the patient diagnosed with ARDS. Studies have shown that patients who are positioned prone and who have respiratory conditions often have improved outcomes of decreased lung atelectasis, mobilization of secretions to enhance suctioning, and decreased fluid accumulation in the lung tissue. 38. C, D, E 39. B 40. D. Rationale: 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. 41. For which patient would NIPPV be an appropriate intervention to promote oxygenation? A. A patient's whose cardiac output and blood pressure are unstable B. A patient whose respiratory failure is caused by a head injury with loss of consciousness C. A patient with a diagnosis of cystic fibrosis and who is producing copious secretions D. A patient who is experiencing respiratory failure as a result of the progression of myasthenia gravis 42. Maintenance of fluid balance in the patient with ARDS involves A. hydration using colloids. B. administration of surfactant. C. mild fluid restriction and diuretics as necessary. D. keeping the hemoglobin level greater than 12 g/dL (120 g/L) 43. Which is a proper nursing action for a patient in acute respiratory failure? A. Administer 100% oxygen to an intubated patient until the pathology has resolved. B. Provide chest physical therapy for patients who produce more than 30 mL of sputum per day. C. Use continuous positive airway pressure (CPAP) if the patient has weak or absent respirations. D. Administer packed red blood cells to maintain the hemoglobin level at 7 g/dL or higher. 44. The high-pressure alarm on a patient’s ventilator goes off. When you enter the room to assess the patient, who has ARDS, the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should you take next? a. Insert an oral airway to prevent the patient from biting on the endotracheal tube b. Reassure the patient that the ventilator will do the work of breathing for him c. Manually ventilate the patient while assessing possible reasons for the highpressure alarm d. Increase the fraction of inspired oxygen on the ventilator to 100% in preparation for endotracheal suctioning 45. The nursing assistant tells you that a patient who is receiving oxygen at a flow rate of 6 L/min by nasal cannula is complaining of nasal passage discomfort. What intervention should you suggest to improve the patient’s comfort for this problem? a. Suggest that the patient sit up in a chair at the bedside b. Suggest that the patient’s oxygen be humidified c. Suggest that a simple face mask be used instead of a nasal cannula d. Suggest that the patient be provided with an extra pillow 46. A patient with acute respiratory distress syndrome (ARDS) is receiving oxygen by a nonrebreather mask, but arterial blood gas measurements still show poor oxygenation. As the nurse responsible for this patient’s care, you would anticipate a physician order for what action? a. Perform endotracheal intubation and initiate mechanical ventilation b. Immediately begin continuous positive airway pressure (CPAP) via the patient’s nose and mouth c. Administer furosemide (Lasix) 100 mg IV push stat d. Call a code for respiratory arrest 47. A patient has been hospitalized in the ICU for a near drowning event. The patient’s respiratory function has been deteriorating over the last 24 hours. The physician suspects acute respiratory distress syndrome. A STAT chest x-ray is ordered. What finding on the chest x-ray is indicative of ARDS? A. infiltrates only on the upper lobes B. enlargement of the heart with bilateral lower lobe infiltrates C. white-out infiltrates bilaterally D. normal chest x-ray 48. You are precepting a nursing student who is assisting you care for a patient on mechanical ventilation with PEEP for treatment of ARDS. The student asks you why the PEEP setting is at 10 mmHg. Your response is: A. “This pressure setting assists the patient with breathing in and out and helps improve air flow.” B. “This pressure setting will help prevent a decrease in cardiac output and hyperinflation of the lungs.” C. “This pressure setting helps prevent fluid from filling the alveoli sacs.” D. “This pressure setting helps open the alveoli sacs that are collapsed during exhalation.” 49. A client has just been intubated for placement on a mechanical ventilator. What is the first assessment of the tube placement? A. Chest X-Ray B. Auscultation of breath sounds C. Pulse oximetry reading of 95% D. End tidal CO2 monitoring 50. What are strategies to prevent Ventilator-associated Pneumonia? select all that apply. 1. Oral care every 4 hours 2. HOB elevated 30-45 degrees unless contraindicated by the patient's condition 3. HOB elevated 10-15 degrees, unless contraindicated by the patient's condition 4. Allow family to suction patient as needed to remove secretions 5. Keeping the bedside clean 51. A Client has been intubated and placed on a volume-cycled mechanical ventilator. The nurse carefully assess the client for findings associated with a risk associated with this type of ventilator. What is the risk? A. Hypoventilation B. Hypercapnia C. Respiratory acidosis D. Barotrauma 52. The client is on CPAP for weaning from a mechanical ventilator. Assessment reveals a respiratory rate of 32/min, oxygen saturation of 88 percent, and use of accessory muscles. What should the nurse anticipate will occur? A. The FiO2 will be increased. B. Weaning will continue. C. The client will be placed back on full ventilatory support. D. The client will be extubated 53. A patient is placed on volume-cycled ventilation. The nurse plans care for this client based on which characteristic of this method of ventilation? A. Delivers a set volume, which will help overcome the client's airway resistance changes. B. The mechanism by which the phase of the breath switches from inspiration to expiration. C. Provides a consistent tidal volume. D. Delivers a preset volume of gas to the lungs to generate high pressures 54. You, the nurse, have been monitoring the client with subcutaneous emphysema around the shoulder and lower neck. You notice that the area has expanded and is traveling up the neck. Based on your knowledge, what should the nurse anticipate doing in the near future? A. Preparing the client for surgery B. Encouraging the client to use the IS C. Palpating the area D. Assisting with tracheostomy insertion 55. The student nurse diligently assesses her patient with a chest tube. She notices that the suction control chamber of the chest tube is not bubbling. What is the first thing this student should do? A. Document this normal finding B. Encourage the patient to cough and deep breathe C. Check the level of the suction on the wall D. Clamp the chest tube and call for help ANSWERS 41-50: 41. D Rationale: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. 42. C. Rationale: Fluid balance in the patient with acute respiratory distress syndrome includes maintaining the pulmonary artery wedge pressure as low as possible without impairing cardiac output to limit pulmonary edema. The patient is usually placed on mild fluid restriction, and diuretics are used as necessary. 43. B Rationale: 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. 44. C 45. B 46. A 47. C 48. D 49. D 50. 1, 2 51. D 52. C 53. A 54. D. Rationale: Subcutaneous emphysema is benign unless it spreads up into the throat and airway. In this event, a tracheostomy may need to be inserted in order to keep the airway open. Encouraging the pt. to use incentive spirometry or palpate the area will not help protect the client's airway or get rid of the subcutaneous emphysema. 55. C. Rationale: The level of suction is controlled by the amount of water in the suction control chamber. However, it would be prudent of the student nurse to check and see if the suction is even turned on. This portion of the chest tube should be gently bubbling, indicating the system is working. Coughing and deep breathing would not help turn the suction on. The student should never clamp the chest tube.