Ch 32: Acute Respiratory Distress Syndrome (ARDS) Flashcards

Question

What is the main reason mechanical ventilation becomes necessary in the exudative phase of ARDS? A. To remove secretions and prevent aspiration B. To prevent CO₂ retention from hypoventilation C. To deliver bronchodilators directly to the lungs D. To provide positive pressure to keep alveoli open

Answer 1

D. To provide positive pressure to keep alveoli open Rationale: With alveolar collapse from loss of surfactant, positive pressure ventilation helps reopen and stabilize alveoli to improve oxygenation.

Answer 2

A. Formation of microemboli C. Increased capillary permeability Rationale: Neutrophils release mediators that increase capillary permeability and contribute to microemboli formation, worsening lung injury.

Answer 3

C. Activation of J receptors due to stiff lungs Rationale: J receptors located in the lung parenchyma are stimulated by fluid accumulation and decreased compliance, causing tachypnea.

Answer 4

D. Hypoxemia does not improve with oxygen Rationale: This is known as refractory hypoxemia, where increasing FiO₂ does not improve oxygenation due to severe shunting and V/Q mismatch.

Answer 5

B. Type II pneumocytes Rationale: Type II alveolar cells synthesize surfactant. In ARDS, damage to these cells leads to surfactant dysfunction and widespread atelectasis.

Answer 6

C. They contribute to hyaline membrane formation Rationale: Protein and fibrin combine with necrotic debris to form hyaline membranes, worsening alveolar collapse and gas exchange.

Answer 7

C. Preparing for intubation and mechanical ventilation Rationale: As ARDS progresses and lungs become stiffer, the work of breathing increases, and mechanical ventilation is often required to support oxygenation.

Answer 8

D. Tachypnea with shallow breathing Rationale: In response to J receptor stimulation and hypoxia, the patient develops tachypnea with a reduced tidal volume.

Answer 9

C. Activation of the inflammatory and immune response Rationale: Neutrophils and other immune cells release cytokines and mediators, leading to capillary membrane damage and fluid leakage into alveoli.

Answer 10

C. It causes alveoli to collapse, worsening shunt Rationale: Without surfactant, alveoli collapse, leading to areas that are perfused but not ventilated (shunt), making oxygen therapy less effective.

Answer 11

D. Causes vasoconstriction and microemboli formation Rationale: Neutrophil activation and inflammation promote vasoconstriction and microemboli, impairing perfusion and worsening oxygenation.

Answer 12

B. Hypoventilation with decreased cardiac output Rationale: As ARDS worsens, compensation fails, leading to hypoventilation, decreased cardiac output, and impaired tissue oxygenation.

Answer 13

D. Thickened alveolar membrane and shunting Rationale: During the proliferative phase, the alveolar membrane becomes fibrotic and thickened, impairing diffusion. V/Q mismatch and shunting continue, leading to persistent hypoxemia.

Answer 14

B. Pulmonary hypertension Rationale: Fibroblast activity and ongoing inflammation destroy the pulmonary vasculature, increasing pulmonary vascular resistance and potentially leading to pulmonary hypertension.

Answer 15

C. Interstitial fibrosis Rationale: Fibroblasts produce collagen and fibrous tissue, leading to interstitial fibrosis, which stiffens the lungs and decreases compliance.

Answer 16

C. Fibroblasts Rationale: Fibroblasts are activated during the proliferative phase and lay down fibrous tissue, contributing to lung stiffness and fibrosis.

Answer 17

D. Use of accessory muscles and prolonged expirations Rationale: Increased secretions and fluid in the airways during this phase contribute to increased airway resistance, often seen as labored breathing and prolonged expiratory effort.

Answer 18

B. Collagen deposition and vascular remodeling Rationale: Fibroblasts lay down collagen, leading to fibrosis and destruction of pulmonary vasculature, which increases pulmonary vascular resistance and pressures.

Answer 19

C. Fibrous tissue replaces diseased lung tissue Rationale: The end of the proliferative phase is marked by the formation of dense fibrous tissue, replacing injured lung areas.

Answer 20

A. Inflammatory cell infiltration decreases Rationale: If the inflammatory response subsides, fibroblast activity declines, and the body may begin to repair tissue rather than form fibrosis.

Answer 21

D. Thickening of alveolar membranes and fibrosis Rationale: Thickened alveolar-capillary membranes and fibrosis impair gas exchange and oxygen diffusion, leading to V/Q mismatch and hypoxemia.

Answer 22

D. Low PaO₂ despite increased PEEP and FiO₂ Rationale: As alveolar membranes thicken and fibrosis develops, oxygen diffusion becomes severely impaired, and refractory hypoxemia persists even with advanced ventilatory support.

Answer 23

C. Decreased lung compliance and refractory hypoxemia Rationale: In the fibrotic phase, interstitial and alveolar fibrosis reduces lung elasticity, making the lungs stiff and noncompliant. The fibrotic tissue limits gas exchange, contributing to persistent hypoxemia despite oxygen therapy.

Answer 24

B. Scarring and fibrosis of lung interstitium Rationale: Widespread fibrosis causes destruction of the alveolar-capillary membrane, significantly reducing the surface area available for gas exchange and contributing to refractory hypoxemia.

Answer 25

B. Reduced lung compliance from fibrotic remodeling Rationale: In the fibrotic stage, collagen and fibrous tissue replace healthy lung parenchyma, making the lungs stiff. This decreased compliance means the patient must generate higher pressures to ventilate, increasing WOB.

Answer 26

C. Higher mortality and long-term pulmonary dysfunction Rationale: Patients who progress to the fibrotic phase have poorer outcomes. The structural lung damage often results in long-term impairment and reduced oxygenation capacity, increasing the risk for chronic respiratory failure or death.

Answer 27

B. Pulmonary hypertension Rationale: Fibrotic destruction of the pulmonary vasculature increases vascular resistance, which can lead to pulmonary hypertension—a common complication in this phase of ARDS.

Answer 28

B. Chest x-ray showing ground-glass opacities Rationale: In the fibrotic phase, imaging like a CT scan often shows diffuse lung scarring and fibrosis, which correlates with decreased compliance and severe, unresponsive hypoxemia.

Answer 29

A. Replacement of lung tissue with fibrotic tissue Rationale: During the fibrotic phase, fibroproliferation leads to dense collagen deposition, replacing functional lung tissue and impairing gas exchange permanently.

Answer 30

D. Scarred interstitial space limiting diffusion Rationale: In the fibrotic stage, diffuse interstitial scarring leads to a thickened diffusion barrier, which significantly reduces oxygen exchange and results in persistent, severe hypoxemia.

Answer 31

C. A patient who has entered the fibrotic phase and developed a pneumothorax Rationale: The fibrotic phase is associated with poorer outcomes. Additional complications like pneumothorax further impair oxygenation and make ventilation difficult, increasing mortality risk.

Answer 32

C. Pulmonary edema resolution and full lung recovery Rationale: In patients who recover during the acute (exudative) phase, pulmonary edema can resolve, and the lungs often return to normal function within a week, assuming no other complications.

Answer 33

D. Nature and extent of the initial lung injury Rationale: The initial injury’s severity plays a key role in determining the clinical trajectory of ARDS. A more severe or widespread injury is likely to result in greater lung damage and progression to the fibrotic phase.

Answer 34

A. Extent of underlying comorbidities Rationale: Comorbid conditions, such as liver disease and diabetes, compromise the immune system and healing capacity, worsening the prognosis and slowing lung recovery in ARDS.

Answer 35

A. Early recognition and prompt initiation of respiratory support Rationale: Timely care, including oxygen therapy or mechanical ventilation, can stabilize gas exchange early and may prevent progression to more severe stages, including the fibrotic phase.

Answer 36

B. The slower-recovering patient had delayed treatment and multiple comorbidities Rationale: Delayed treatment and the presence of comorbidities (e.g., cardiac, renal, hepatic) negatively affect the healing process, making recovery from ARDS more prolonged and complicated.

Answer 37

D. Genetic predisposition to ARDS Rationale: Although not fully understood, genetic factors can influence the body’s inflammatory and healing responses, potentially making some patients more susceptible to progression or complications of ARDS.

Answer 38

C. Because of severely reduced lung compliance Rationale: In the fibrotic stage, dense collagen deposition makes lungs extremely stiff, requiring higher airway pressures to ventilate and often necessitating long-term mechanical support.

Answer 39

D. Progressive reduction in pulmonary edema Rationale: Improvement in pulmonary edema suggests resolution of the acute inflammatory process, signaling early recovery and better prognosis in ARDS.

Answer 40

B. Mild dyspnea, tachypnea, and restlessness Rationale: The initial presentation of ARDS is often subtle, with symptoms like mild dyspnea, tachypnea, and restlessness. Severe symptoms typically develop after 24 to 72 hours.

Answer 41

B. Hyperventilation caused by an early compensatory response Rationale: In the early stages of ARDS, hyperventilation occurs as a compensatory response to initial hypoxemia, causing respiratory alkalosis. This is often followed by progressive hypoxemia as the disease progresses.

Answer 42

B. Diffuse and extensive bilateral interstitial and alveolar infiltrates Rationale: After 72 hours, a chest x-ray typically reveals diffuse and extensive bilateral infiltrates, indicating the progression of ARDS as fluid accumulates in the lungs.

Answer 43

A. <100 Rationale: A P/F ratio of less than 100 indicates severe ARDS, reflecting significant impairment of oxygenation despite high levels of oxygen delivery.

Answer 44

A. Refractory hypoxemia unresponsive to increasing FIO2 Rationale: Refractory hypoxemia is the hallmark feature of ARDS, where oxygenation continues to deteriorate despite increased FIO2, distinguishing it from other forms of respiratory failure.

Answer 45

B. Cyanosis, diaphoresis, and mental status changes Rationale: Cyanosis, diaphoresis, and mental status changes indicate worsening hypoxemia and respiratory failure, which require immediate intervention.

Answer 46

A. Respiratory acidosis and high CO2 Rationale: As ARDS progresses, respiratory muscle fatigue leads to hypoventilation, causing respiratory acidosis with an increase in CO2 levels due to impaired gas exchange.

Answer 47

D. Fine, scattered crackles that progress to coarse crackles on expiration Rationale: As ARDS progresses, lung auscultation will show fine, scattered crackles that later become coarse crackles, reflecting the accumulation of fluid in the alveoli and airways.

Answer 48

A. Severe pulmonary edema and increased work of breathing Rationale: Intercostal and suprasternal retractions are signs of increased work of breathing due to severe pulmonary edema and reduced lung compliance, indicating worsening ARDS.

Answer 49

B. Moderate ARDS Rationale: A P/F ratio of 150 indicates moderate ARDS. Mild ARDS would have a ratio of 200-300, while severe ARDS would have a ratio of less than 100.

Answer 50

B. Represents widespread consolidation and loss of recognizable air spaces Rationale: The term “whiteout” refers to widespread consolidation and loss of air spaces due to severe pulmonary edema in ARDS, confirming progression of the disease.

Answer 51

D. Increased capillary permeability and fluid leakage into the pleural space Rationale: Increased capillary permeability in ARDS leads to the leakage of fluid into the pleural space, resulting in pleural effusions.

Answer 52

B. Respiratory acidosis with high PaCO2 and low pH Rationale: Respiratory acidosis with high PaCO2 and a low pH signals severe ventilation failure and impending respiratory failure as the patient is unable to compensate for hypoventilation.

Answer 53

D. The patient is experiencing severe respiratory distress. Rationale: Suprasternal retractions indicate that the patient is in severe respiratory distress and struggling to breathe effectively. This sign suggests worsening ARDS with increased work of breathing.

Answer 54

A. The patient is developing respiratory failure due to muscle fatigue. Rationale: Increasing PaCO2 and decreasing PaO2 typically indicate respiratory failure due to respiratory muscle fatigue in ARDS, where the lungs are unable to provide adequate oxygenation and ventilation.

Answer 55

B. The type of initial injury and extent of lung damage Rationale: The type of initial injury (e.g., trauma, aspiration, pneumonia) and the extent of lung damage are the most significant factors influencing the clinical course and outcome of ARDS. Early and appropriate intervention is crucial to improving survival rates.

Answer 56

C. Exudative (acute) phase Rationale: The presence of bilateral interstitial infiltrates and alveolar damage on a chest x-ray suggests that the patient is in the exudative (acute) phase of ARDS, where inflammatory changes lead to fluid accumulation and impaired gas exchange.

Answer 57

C. Multiple organ dysfunction syndrome Rationale: The primary cause of death in ARDS patients is MODS, often accompanied by sepsis. This systemic complication leads to failure of multiple vital organs, including the kidneys, liver, and heart.

Answer 58

B. Pneumothorax Rationale: Pneumothorax is a common complication of mechanical ventilation in patients with ARDS, due to increased airway pressures or barotrauma. This can lead to further deterioration in respiratory function.

Answer 59

B. Monitoring for signs of systemic infection and treating with antibiotics Rationale: In patients with ARDS, sepsis is a common cause of MODS. Early detection and treatment of systemic infection with antibiotics is essential to prevent worsening organ dysfunction and improve survival outcomes.

Answer 60

D. Persistent scarring and fibrosis in the lungs Rationale: Persistent scarring and fibrosis in the lungs are common in ARDS survivors, contributing to ongoing symptoms such as shortness of breath, fatigue, and dyspnea, even after recovery. Scarring may impact lung function for years.

Answer 61

D. Severity of the initial lung injury and extent of scarring Rationale: The severity of the initial lung injury and the extent of scarring are key factors in long-term lung function recovery. Mechanical ventilation and extracorporeal life support may contribute to recovery, but the degree of lung injury and fibrosis plays a significant role.

Answer 62

C. Encouraging the patient to use supplemental oxygen during exertion Rationale: Patients with persistent dyspnea and fatigue after ARDS may benefit from supplemental oxygen during exertion, which can help improve oxygenation and alleviate symptoms. Long-term management focuses on optimizing function and managing symptoms, not over-reliance on medications.

Answer 63

B. Persistent abnormal lung function can last for years, with some patients having lifelong impairment. Rationale: While some patients may recover normal lung function, persistent abnormal lung function can last for years or may even result in lifelong impairment due to scarring and fibrosis in the lungs. Mechanical ventilation and extracorporeal life support can also contribute to long-term changes.

Answer 64

A. Chest pain, shortness of breath, and fatigue after minimal activity Rationale: Many ARDS survivors report persistent chest pain, shortness of breath, and fatigue after minimal activity due to residual lung damage and scarring. These symptoms are common long-term effects following the resolution of the acute phase.

Answer 65

D. “I should expect my lung function to return to normal in the next few weeks.” Rationale: This statement reflects an unrealistic expectation of immediate recovery. While some patients may regain near-normal lung function, others experience persistent symptoms, and it can take months to years for full recovery, if at all. Education should emphasize the possibility of long-term symptoms.

Answer 66

A) Aspiration due to enteral nutrition Rationale: Patients receiving enteral nutrition (EN) are at higher risk for aspiration, which is one of the risk factors for VAP. Aspiration can introduce bacteria into the lungs, leading to infection and the development of VAP.

Answer 67

B) Implementing a ventilator bundle protocol Rationale: A ventilator bundle protocol, which includes evidence-based practices such as elevating the head of the bed, oral care, and appropriate sedation management, is effective in reducing the incidence of VAP in mechanically ventilated patients.

Answer 68

A) Prolonged mechanical ventilation Rationale: Prolonged mechanical ventilation is a key risk factor for VAP. Longer durations of ventilation increase the likelihood of ventilator-associated infections due to impaired host defenses and the use of invasive devices.

Answer 69

B) Providing frequent oral care with chlorhexidine Rationale: Providing frequent oral care with chlorhexidine has been shown to reduce the incidence of VAP by minimizing the buildup of bacterial pathogens in the mouth, which can be aspirated into the lungs.

Answer 70

D) Providing ventilation with a smaller tidal volume (VT) of 4 to 8 mL/kg Rationale: Using a smaller tidal volume of 4 to 8 mL/kg reduces the risk of overdistending the fragile alveoli, which can prevent barotrauma. This approach minimizes the chance of lung injury and complications such as pneumothorax and subcutaneous emphysema.

Answer 71

A) Ventilation with excessive tidal volume (VT) Rationale: Barotrauma, which can cause pneumothorax, is most often a result of excessive tidal volume (VT) or high peak airway pressures. Overdistending the alveoli during mechanical ventilation increases the risk of alveolar rupture and subsequent pneumothorax.

Answer 72

B) Decreased breath sounds on one side, hypotension, and tachypnea Rationale: Decreased breath sounds on one side, hypotension, and tachypnea are classic signs of pneumothorax, which is a complication of barotrauma. The rupture of alveoli allows air to escape into the pleural space, leading to a collapsed lung and associated symptoms.

Answer 73

B) To minimize the risk of overdistending fragile alveoli and causing lung injury Rationale: Decreasing the tidal volume reduces the risk of overdistending fragile alveoli, which can prevent barotrauma. Smaller tidal volumes help minimize the risk of ventilator-associated lung injury, including complications like pneumothorax and subcutaneous emphysema.

Answer 74

C) Correcting predisposing conditions, such as hypotension and acidosis Rationale: Correcting predisposing conditions, such as hypotension, shock, and acidosis, is essential to prevent GI ulcers. Adequate perfusion to the GI system is necessary to prevent ischemic damage that can lead to ulcers. Prophylactic treatment and enteral nutrition are also important.

Answer 75

A) Pantoprazole Rationale: Pantoprazole is a proton pump inhibitor (PPI) that reduces gastric acid secretion, helping to prevent GI ulcers. PPIs are commonly used for prophylactic ulcer management in critically ill patients, particularly those with ARDS and ARF.

Answer 76

B) It reduces the risk of developing GI ulcers Rationale: Early enteral nutrition helps maintain mucosal integrity in the gastrointestinal system, reducing the risk of GI ulcers in critically ill patients. It supports the gut’s function, preventing ischemic damage due to inadequate blood flow.

Answer 77

C) Osteoporosis with long-term use Rationale: Long-term use of proton pump inhibitors (PPIs) like pantoprazole can increase the risk of osteoporosis, particularly in patients who require prolonged therapy. PPIs reduce gastric acid secretion, which can impair calcium absorption and contribute to bone weakening over time.

Answer 78

B) To protect the mucosal lining of the GI tract Rationale: Sucralfate is a mucosal-protecting drug that forms a protective barrier over ulcerated areas in the GI tract, helping to prevent further damage. This is particularly important in patients at risk for GI ulcers, such as those with ARDS and ARF.

Answer 79

B) Applying intermittent pneumatic compression stockings Rationale: Intermittent pneumatic compression stockings help prevent DVT by promoting circulation and preventing venous stasis. This is especially important in critically ill patients, such as those with ARDS, who are immobile and at higher risk for VTE.

Answer 80

A) Platelet count Rationale: Prior to administering heparin, it is essential to assess the platelet count to monitor for potential heparin-induced thrombocytopenia (HIT). Low platelet counts could indicate the development of HIT, a serious complication of anticoagulation therapy.

Answer 81

C) It enhances circulation and reduces venous stasis Rationale: Early ambulation helps to enhance circulation and reduce venous stasis, which is a key factor in preventing venous thromboembolism (VTE). This is especially important for patients with ARDS, who are often immobile and at increased risk for DVT and pulmonary embolism.

Answer 82

B) Monitoring daily creatinine and urea levels Rationale: Monitoring creatinine and urea levels is crucial to assess kidney function in patients at risk for AKI. This helps in early detection of renal impairment, which is especially important in patients with ARDS.

Answer 83

D) It is slower and gentler, which is better tolerated in hemodynamically unstable patients Rationale: CRRT is slower and gentler than traditional hemodialysis, which is particularly beneficial for patients who are hemodynamically unstable, as they cannot tolerate the large fluid shifts and volumes removed by conventional dialysis.

Answer 84

C) Blood pressure and heart rate Rationale: Before initiating CRRT, it is crucial to assess the patient’s blood pressure and heart rate, as CRRT can affect hemodynamic stability. Monitoring these parameters ensures that the patient remains stable while undergoing the therapy, especially since vasopressors are being used.

Answer 85

A) Vancomycin Rationale: Vancomycin is a nephrotoxic drug commonly used to treat infections in ARDS patients, and it is associated with an increased risk of acute kidney injury (AKI). Monitoring renal function is crucial in patients receiving this medication.

Answer 86

C) Hypotension Rationale: Hypotension is a potential complication of CRRT, especially in patients with ARDS and AKI. Since CRRT is a continuous process, it can lead to gradual shifts in fluid and electrolytes, potentially resulting in hypotension.

Answer 87

B) Maintenance of hemodynamic stability Rationale: One of the key benefits of CRRT is its ability to maintain hemodynamic stability in critically ill patients. Unlike traditional hemodialysis, CRRT is slow and continuous, which reduces the risk of sudden fluid shifts that could cause hypotension.

Answer 88

A) Administering vasopressors Rationale: In patients with hypotension, especially those with ARDS and AKI, vasopressors are used to support renal perfusion by raising blood pressure and maintaining adequate blood flow to the kidneys.

Answer 89

A) Hypovolemia Rationale: CRRT can lead to hypovolemia, especially if fluid removal exceeds the patient’s capacity to compensate. The nurse should monitor the patient for signs of hypovolemia and adjust the CRRT settings as necessary.

Answer 90

C) Referring the patient for a psychiatric evaluation and therapy Rationale: Survivors of ARDS may experience symptoms of PTSD, anxiety, and depression. It is essential to refer the patient for a psychiatric evaluation to ensure proper diagnosis and treatment, which may include therapy or counseling, rather than solely relying on medication or physical rehabilitation.

Answer 91

B) Psychological issues such as PTSD and depression can persist even after recovery Rationale: Survivors of ARDS often experience long-lasting psychological issues, such as PTSD and depression, which can persist for months or even years after recovery. These mental health issues may hinder their overall recovery process, and addressing them is an essential part of care.

Answer 92

A) Norepinephrine Rationale: Norepinephrine is a vasopressor used to maintain blood pressure in patients with ARDS who are experiencing hypotension. It helps increase vascular tone and improve perfusion to vital organs. The other medications listed are not appropriate for managing hypotension in this context.

Answer 93

B) Ensuring adequate sedation and analgesia Rationale: Neuromuscular blocking agents are used to paralyze the patient to facilitate mechanical ventilation. It is crucial to ensure that the patient is adequately sedated and receiving analgesia to prevent discomfort and anxiety while paralyzed. Continuous monitoring of oxygen saturation is also important, but sedation and analgesia are the priority.

Answer 94

A) Patients with severe hemodynamic instability despite conventional mechanical ventilation Rationale: ECMO is a life-saving intervention for patients with ARDS who are severely unstable despite conventional mechanical ventilation. It provides cardiac and respiratory support, improving oxygenation and removing CO2. It is typically not used for mild cases of ARDS or for patients with minimal mechanical ventilation needs.

Answer 95

D) Tachycardia Rationale: Dobutamine is an inotropic drug used to improve cardiac output in ARDS patients. It can cause tachycardia as a side effect, which should be closely monitored to prevent further complications such as arrhythmias. The other side effects listed are not as closely associated with dobutamine use.

Answer 96

A) Prevent fluid overload and reduce pulmonary edema Rationale: In ARDS management, maintaining the patient on the “dry side” means restricting fluid intake to prevent fluid overload and reduce the risk of worsening pulmonary edema. This strategy is essential to optimize oxygenation and prevent further complications.

Answer 97

A) Starting enteral nutrition as soon as possible Rationale: Early enteral nutrition (EN) is essential for ARDS patients to prevent mucosal damage and maintain nutritional status, as it helps to support healing and immune function. This approach is preferred over parenteral nutrition, as EN is associated with fewer complications.

Answer 98

B) Elevating the head of the bed to 30 to 45 degrees Rationale: Elevating the head of the bed to 30 to 45 degrees helps reduce the risk of aspiration, which is a primary risk factor for VAP. This positioning strategy is part of the VAP bundle, which also includes oral care, sedation minimization, and deep vein thrombosis prophylaxis.

Answer 99

A) Prevent barotrauma by minimizing excessive lung pressure Rationale: Low tidal volume (VT) ventilation is used in ARDS patients to prevent barotrauma, which can occur when high pressure is applied to fragile alveoli. By using a smaller tidal volume, the risk of overdistension and lung injury is reduced.

Answer 100

A) Allowing for higher than normal levels of carbon dioxide (CO2) in the blood Rationale: Permissive hypercapnia is a strategy used in ARDS management that allows higher levels of CO2 in the blood in order to reduce ventilatory pressures and minimize the risk of barotrauma. The goal is to prevent overventilation and promote lung protection.

Answer 101

C) Tachycardia Rationale: Dopamine is an inotropic medication that helps increase cardiac output and blood pressure. A known side effect of dopamine is tachycardia. The nurse should monitor the patient’s heart rate and rhythm closely to prevent adverse effects such as arrhythmias.

Answer 102

C) Initiate mechanical ventilation and protect the airway Rationale: The immediate priority in ARDS is to protect the airway and initiate mechanical ventilation to ensure proper oxygenation. While inserting lines and administering vasopressors are necessary later, securing the airway and providing respiratory support are the most critical interventions.

Answer 103

B) Cyanosis and altered mental status Rationale: Cyanosis (bluish discoloration of the skin due to lack of oxygen) and altered mental status are common signs of respiratory failure in ARDS patients. These findings are due to inadequate oxygenation and may indicate worsening respiratory distress or failure.

Answer 104

B) Immediate mechanical ventilation and interventions are needed Rationale: In ARDS, immediate interventions such as intubation, mechanical ventilation, and the initiation of vasopressors are required to stabilize the patient. This urgent care need often prevents the nurse from obtaining complete subjective and objective data during the initial assessment.

Answer 105

B) Obtain vital signs and assess respiratory status Rationale: The nurse’s priority in ARDS assessment is to obtain vital signs and assess the patient’s respiratory status, as this directly impacts the patient’s oxygenation and overall condition. Although a full assessment is important, addressing airway, breathing, and circulation is the immediate priority in a critically ill patient.

Answer 106

C) Administering supplemental oxygen and adjusting settings on the ventilator Rationale: Administering supplemental oxygen and adjusting ventilator settings is crucial to increasing PaO2 levels and achieving adequate lung ventilation, which is a key goal in ARDS management.

Answer 107

B) Monitoring and adjusting the ventilator settings as needed Rationale: Monitoring and adjusting the ventilator settings, such as optimizing PEEP and tidal volumes, is essential to improving PaO2 levels and meeting the long-term goal for ARDS patients.

Answer 108

B) Turning the patient every 2 hours to improve ventilation and perfusion Rationale: Regular repositioning helps improve ventilation and perfusion, which is essential for increasing SaO2 levels in ARDS patients.

Answer 109

C) Implementing a mechanical ventilator strategy that limits tidal volume Rationale: Limiting tidal volume helps prevent barotrauma and supports lung protection, which can help in achieving the goal of clear lungs on auscultation.

Answer 110

B) To prevent overdistention of the alveoli and reduce the risk of barotrauma Rationale: Low tidal volume ventilation helps prevent overdistention of the alveoli and reduces the risk of barotrauma, which is important in ARDS patients to minimize further lung injury.

Answer 111

D) To allow the body to tolerate higher levels of carbon dioxide without causing harm Rationale: Permissive hypercapnia allows the body to tolerate higher levels of CO2, which helps minimize ventilator-associated lung injury by avoiding excessively high tidal volumes or peak pressures.

Answer 112

A) It helps to maintain alveolar patency and improve oxygenation Rationale: PEEP helps maintain alveolar patency, preventing alveolar collapse, and improves oxygenation by promoting the recruitment of lung tissue.

Answer 113

D) When the patient’s oxygenation cannot be adequately supported by conventional mechanical ventilation Rationale: ECMO is used to support oxygenation when conventional mechanical ventilation is unable to adequately oxygenate the patient, allowing time for lung recovery.

Answer 114

D) Continuous heart rate and respiratory rate Rationale: Continuous monitoring of heart rate and respiratory rate is essential to assess the patient’s response to mechanical ventilation and detect potential complications such as respiratory distress or ventilator-associated events.

Answer 115

B) To correct hypoxemia and improve oxygen delivery to tissues Rationale: The primary goal of oxygen therapy is to correct hypoxemia, improving oxygen delivery to the tissues and organs, which is crucial in ARDS management.

Answer 116

C) A lower PaO2 and SpO2 are accepted to minimize ventilator-induced lung injury Rationale: A lower-than-normal PaO2 and SpO2 are often accepted in ARDS patients to minimize ventilator-induced lung injury and reduce the risk of oxygen toxicity, especially during the injury and reparative phases.

Answer 117

B) Administer a higher FIO2 and closely monitor SpO2 Rationale: Administering a higher FIO2 and closely monitoring SpO2 are appropriate interventions for patients with ARDS to maintain an acceptable PaO2 level.

Answer 118

C) Use of higher levels of PEEP to maintain alveolar recruitment Rationale: Increasing PEEP helps to maintain alveolar recruitment and improve oxygenation, especially in ARDS patients who require higher levels of FIO2 to maintain adequate PaO2.

Answer 119

A) BiPAP does not provide enough oxygen to maintain adequate PaO2 levels in severe ARDS Rationale: BiPAP is effective for a limited time in ARDS because, as respiratory failure worsens, high-flow oxygen cannot maintain acceptable PaO2 levels, necessitating mechanical ventilation for more effective oxygenation.

Answer 120

D) Prepare for intubation and mechanical ventilation to maintain PaO2 Rationale: When high-flow oxygen therapy no longer maintains PaO2 levels within acceptable ranges, mechanical ventilation should be initiated to provide more effective oxygenation and support for the patient.

Answer 121

B) To avoid ventilator-induced lung injury and oxygen toxicity Rationale: Maintaining PaO2 and SpO2 within these lower ranges helps reduce the risk of ventilator-induced lung injury and oxygen toxicity during the reparative phase of ARDS.

Answer 122

A) To reduce ventilator-associated lung injury by avoiding high peak airway pressures Rationale: Permissive hypercapnia is used to reduce ventilator-associated lung injury by avoiding high peak airway pressures, which can cause further lung damage in ARDS patients.

Answer 123

B) It maintains low inspiratory and plateau pressures to prevent alveolar overdistention Rationale: Pressure-control ventilation helps prevent alveolar overdistention by maintaining low inspiratory and plateau pressures, which reduces the risk of lung injury in ARDS patients.

Answer 124

B) Alveolar overdistention and rupture Rationale: The primary goal of pressure-control ventilation in ARDS is to prevent alveolar overdistention and rupture, which can lead to further lung injury.

Answer 125

C) Adjust the pressure settings to prevent further overdistention Rationale: Adjusting the pressure settings to prevent further overdistention is crucial when the plateau pressure is rising, as high pressures can lead to lung injury in ARDS patients.

Answer 126

B) The specific lung condition and severity of ARDS Rationale: The choice of ventilation mode for ARDS patients depends on the severity of the condition and the specific lung issues, with modes adjusted to minimize injury and maximize oxygenation.

Answer 127

B) To prevent barotrauma and volutrauma associated with stiff lungs Rationale: The primary reason for using a low tidal volume (4 to 8 mL/kg) in ARDS patients is to prevent barotrauma and volutrauma, which can occur from delivering large volumes of air into stiff, noncompliant lungs.

Answer 128

A) Alveolar fractures and damage to the alveolar-capillary membrane Rationale: Volutrauma refers to alveolar fractures and damage to the alveolar-capillary membrane, which can lead to fluid and protein accumulation in the alveolar spaces. Using a low tidal volume helps prevent this type of injury.

Answer 129

B) Volutrauma and barotrauma Rationale: Low tidal volume ventilation helps to reduce the risks of volutrauma and barotrauma, which are complications that can result from delivering excessive tidal volumes to stiff lungs in ARDS.

Answer 130

C) Decreased mortality and reduced risk for volutrauma Rationale: Low tidal volume ventilation has been shown to decrease mortality in ARDS patients by reducing the risk of volutrauma and improving lung protection during mechanical ventilation.

Answer 131

D) To allow the brain and systemic circulation to compensate for the rise in CO2 Rationale: Permissive hypercapnia occurs as a consequence of low tidal volume ventilation. The gradual rise in PaCO2 allows the brain and systemic circulation to compensate for this change, which helps protect the lungs from further injury.

Answer 132

C) Continue monitoring, ensuring the pH remains within 7.30–7.45 and the patient is stable Rationale: In permissive hypercapnia, a gradual rise in PaCO2 is acceptable, as long as the pH remains within the target range (7.30–7.45). The nurse should continue monitoring and ensure the patient is stable before making any changes.

Answer 133

B) A 30-year-old pregnant female with ARDS Rationale: Permissive hypercapnia is not used in pregnant patients, as the rising PaCO2 can be harmful to both the mother and fetus.

Answer 134

A) PaCO2 Rationale: Permissive hypercapnia involves allowing the PaCO2 to rise above normal levels (up to 60 mm Hg). This will directly affect the PaCO2 values.

Answer 135

B) 7.30–7.45 Rationale: The pH should be maintained between 7.30 and 7.45 to prevent acidosis and allow for appropriate compensation during permissive hypercapnia.

Answer 136

A) Continuous IV analgesia and sedation Rationale: To manage permissive hypercapnia, continuous IV analgesia and sedation are often used to ensure the patient’s comfort and tolerance to the rising PaCO2.

Answer 137

C) The rise in PaCO2 is acceptable, and the pH is within the normal range. Rationale: In permissive hypercapnia, a rise in PaCO2 is acceptable if the pH remains within the normal range (7.30–7.45), and the patient is tolerating the change.

Answer 138

A) To increase functional residual capacity and recruit collapsed alveoli Rationale: The primary goal of increasing PEEP is to increase functional residual capacity and recruit collapsed alveoli, which improves oxygenation by preventing the collapse of small airways.

Answer 139

C) Decreased venous return and compromised cardiac output Rationale: Higher levels of PEEP can compromise venous return to the heart, reducing cardiac output and preload, which can lead to hypotension and decreased oxygen delivery.

Answer 140

A) Increased risk of barotrauma and volutrauma Rationale: Increasing PEEP to higher levels, such as 15 cm H2O, can increase the risk of barotrauma and volutrauma, potentially causing damage to the alveoli and surrounding tissues.

Answer 141

B) Administer fluids or vasopressors to improve venous return Rationale: If hypotension occurs with high PEEP, the best intervention is to administer fluids or vasopressors to improve venous return and restore cardiac output, as high PEEP can reduce preload and compromise BP.

Answer 142

D) Increases the risk of barotrauma and decreases cardiac output Rationale: Increasing PEEP can improve alveolar recruitment but also increases the risk of barotrauma and reduces cardiac output due to decreased venous return.

Answer 143

A) Decrease the PEEP to reduce the intrathoracic pressure Rationale: Decreasing the PEEP can help reduce the intrathoracic pressure and improve venous return, which may help increase blood pressure by restoring cardiac output and preload.

Answer 144

B) Decreased preload and cardiac output Rationale: High levels of PEEP, such as 20 cm H2O, can significantly reduce preload and cardiac output by increasing intrathoracic pressures, leading to a decrease in venous return and potentially causing hypotension.

Answer 145

C) To prevent alveolar collapse and improve oxygenation Rationale: The primary purpose of applying PEEP is to prevent alveolar collapse, improving oxygenation by increasing functional residual capacity and recruiting collapsed alveoli.

Answer 146

D) To better match perfusion to ventilation and improve oxygenation Rationale: The primary goal of prone positioning in ARDS patients is to improve oxygenation by better matching perfusion to ventilation, allowing alveoli in the posterior lungs to re-expand.

Answer 147

B) Hemodynamic instability, including dysrhythmias and decreased blood pressure Rationale: While prone positioning can improve oxygenation, it may also cause hemodynamic instability, including dysrhythmias and a decrease in blood pressure due to fluid shifts.

Answer 148

C) Securing and maintaining the airway throughout the procedure Rationale: Securing and maintaining the airway is the most important consideration when placing a patient in the prone position, as airway management is critical to prevent complications.

Answer 149

A) Decrease the PEEP and FiO2 settings Rationale: If there is an improvement in PaO2, it may be appropriate to decrease PEEP and FiO2 settings. This can help maintain oxygenation while reducing the risk of oxygen toxicity and barotrauma.

Answer 150

B) Up to 16 hours per day Rationale: Research suggests that patients with ARDS can remain in the prone position for up to 16 hours per day to maximize benefits in improving oxygenation.

Answer 151

C) Increased need for airway suctioning as secretions are mobilized Rationale: While the patient is in the prone position, secretions are mobilized, which can lead to an increased need for airway suctioning to prevent airway obstruction and improve ventilation.

Answer 152

B) Ensure the patient’s blood pressure is stable before turning Rationale: Before turning the patient prone, it is essential to ensure the patient’s blood pressure is stable to avoid hemodynamic instability during fluid shifts that can occur when prone.

Answer 153

A) Continuous lateral rotation therapy (CLRT) Rationale: Continuous lateral rotation therapy (CLRT) is an alternative to prone positioning that rotates the patient side-to-side to simulate postural drainage and help mobilize secretions.

Answer 154

D) Properly securing and maintaining the airway Rationale: Securing and maintaining the airway is critical to ensure patient safety during prone positioning, as the patient may be at increased risk of airway compromise.

Answer 155

D) Assist in turning and positioning the patient safely, ensuring airway management Rationale: The nurse’s primary role is to assist with turning the patient safely into the prone position, ensuring the airway is managed and protected throughout the procedure.

Answer 156

D) An improvement in PaO2 and oxygenation Rationale: If prone positioning is successful, there is likely to be an improvement in PaO2 and overall oxygenation due to better matching of ventilation and perfusion.

Answer 157

C) As early as possible in the course of ARDS Rationale: Research suggests that initiating prone positioning as early as possible in the course of ARDS can lead to better outcomes by improving oxygenation early on.

Answer 158

C) Changes in cardiac output and blood pressure Rationale: When a patient is placed in the prone position, there can be changes in cardiac output and blood pressure due to fluid shifts, so it is essential to monitor these closely for any signs of hemodynamic instability.

Answer 159

B) ECMO delivers oxygen into the blood and removes CO2, then returns oxygenated blood to the patient Rationale: ECMO functions by delivering oxygen to the blood and removing CO2, which is then returned to the patient. It serves as a temporary life support system for patients with severe respiratory or cardiac failure.

Answer 160

A) Monitor the patient for signs of fluid overload due to blood flow changes Rationale: Monitoring for signs of fluid overload is crucial because the increased blood flow and extracorporeal circulation can lead to hemodynamic changes that may contribute to fluid imbalance.

Answer 161

C) ECMO supports both oxygenation and carbon dioxide removal, while ECCO2R is used only to enhance oxygenation Rationale: ECMO supports both oxygenation and carbon dioxide removal, whereas ECCO2R is primarily used to enhance oxygenation and does not require as high blood flow rates as ECMO.

Answer 162

A) It requires high blood flow rates to ensure adequate oxygenation Rationale: ECMO requires high blood flow rates to be effective in oxygenating blood and removing carbon dioxide. It is a complex and expensive procedure that demands specialized training for healthcare personnel.

Answer 163

D) Frequently assessing the cannulation sites for signs of infection or complications Rationale: Frequent assessment of the cannulation sites for infection, bleeding, or other complications is essential for patient safety and effective ECMO management. ECMO requires specialized care, and the patient should be monitored closely for adverse effects.

Answer 164

A) To prevent ventilator dyssynchrony and reduce work of breathing Rationale: Analgesia and sedation help reduce discomfort from the ET tube, decrease the work of breathing, and prevent ventilator dyssynchrony, improving overall patient comfort and ventilation effectiveness.

Answer 165

B) The patient may appear to be asleep but still feel pain, so analgesia and sedation must be given simultaneously Rationale: When using NMBAs, it is essential to simultaneously administer analgesia and sedation, as the patient can still experience pain despite being paralyzed by the NMBA. Monitoring and providing adequate sedation is critical.

Answer 166

C) A peripheral nerve stimulator should be used to assess the depth of paralysis Rationale: A peripheral nerve stimulator is used to assess the depth of paralysis in patients receiving NMBA. This helps ensure the patient is adequately sedated and that paralysis is at the correct level for synchronization with the ventilator.

Answer 167

C) Ventilator dyssynchrony and patient discomfort Rationale: Inadequate sedation or analgesia can lead to ventilator dyssynchrony, which increases patient discomfort and impedes effective ventilation, resulting in poor outcomes.

Answer 168

D) Use a peripheral nerve stimulator to monitor the depth of paralysis Rationale: A peripheral nerve stimulator is an effective tool for monitoring the depth of paralysis in patients receiving NMBA, ensuring they are appropriately sedated and paralyzed without excessive sedation or pain.

Answer 169

D) The patient is not receiving enough neuromuscular blockade Rationale: If ventilator dyssynchrony occurs despite appropriate sedation, it may indicate that the patient is not receiving enough neuromuscular blockade. This can prevent the patient from synchronizing their breathing with the ventilator, even if they are adequately sedated.

Answer 170

A) To promote synchrony between the patient and the ventilator Rationale: The primary goal of using NMBAs is to promote synchrony between the patient and the ventilator, ensuring that the patient’s breathing aligns with the ventilator settings and reducing ventilator dyssynchrony.

Answer 171

A) Increased intrathoracic pressure leading to decreased venous return Rationale: The increase in intrathoracic pressure caused by PEEP reduces venous return, which in turn decreases cardiac output (CO).

Answer 172

B) Hyperinflation of the alveoli causing increased right ventricular afterload Rationale: Alveolar hyperinflation due to PEEP increases right ventricular afterload, impairing blood flow from the right side of the heart and leading to a decrease in CO.

Answer 173

D) A decrease in blood pressure and oxygen saturation Rationale: A decrease in blood pressure and oxygen saturation are early indicators of decreased CO, suggesting a lack of adequate tissue perfusion.

Answer 174

C) Central venous pressure (CVP) Rationale: Central venous pressure (CVP) is an essential parameter to monitor as it provides information about venous return, preload, and the overall hemodynamic status of the patient.

Answer 175

C) To restore normal blood pressure and improve tissue perfusion Rationale: The primary goal of IV fluids and vasoactive medications in this scenario is to restore normal blood pressure and improve tissue perfusion, addressing the decrease in CO.

Answer 176

B) Increased blood pressure and stable heart rate Rationale: Increased blood pressure and a stable heart rate indicate adequate tissue perfusion. These parameters suggest that the heart is effectively pumping blood and oxygen to the tissues.

Answer 177

C) Increased intrathoracic pressure leading to reduced venous return Rationale: Increased intrathoracic pressure caused by PPV can reduce venous return, leading to decreased CO due to impaired preload and decreased right ventricular filling.

Answer 178

C) Decrease in central venous pressure (CVP) Rationale: A decrease in CVP may indicate inadequate preload or venous return, requiring further intervention to optimize tissue perfusion.

Answer 179

D) Adjustment of ventilator settings to decrease intrathoracic pressure Rationale: Adjusting ventilator settings to decrease intrathoracic pressure can help improve venous return, which may improve CO and tissue perfusion in the patient with ARDS.

Answer 180

B) Monitor hemodynamic parameters, urine output, and daily weights Rationale: Monitoring hemodynamic parameters, urine output, and daily weights is crucial for assessing fluid volume status in ARDS patients. It helps prevent both fluid overload and dehydration, managing the delicate balance of fluid.

Answer 181

A) Start enteral nutrition immediately within 24 to 48 hours Rationale: Enteral nutrition (EN) should be started as soon as possible within 24 to 48 hours to maintain protein and energy stores. This helps prevent muscle loss, including respiratory muscles, which can prolong mechanical ventilation.

Answer 182

C) Begin enteral nutrition as soon as possible to prevent muscle mass loss Rationale: Starting enteral nutrition (EN) within 24 to 48 hours is essential to maintain protein and energy stores, preventing muscle loss, including respiratory muscles, and reducing the risk of prolonged mechanical ventilation.

Answer 183

C) They are rarely effective in ARDS because of the inflammatory nature of the condition. Rationale: Diuretics play a minimal role in managing fluid retention in ARDS due to the inflammatory nature of the condition. Fluid management is better achieved through careful monitoring of fluid intake, output, and hemodynamic parameters.

Answer 184

B) Strict monitoring of intake and output, along with daily weights Rationale: Strict monitoring of intake and output, along with daily weights, is essential to prevent excessive fluid retention and maintain fluid balance in ARDS patients. It helps identify early signs of fluid overload, such as pulmonary edema.

Answer 185

D) Administering diuretics to rapidly remove fluid from the body Rationale: Diuretics should be used minimally in ARDS patients because of the inflammatory nature of the condition. Aggressive fluid removal can worsen hemodynamic instability and should be avoided in favor of more cautious fluid management strategies.

Answer 186

C) The patient maintains adequate oxygenation with decreasing amounts of oxygen. Rationale: Successful management of ARDS includes the patient maintaining adequate oxygenation and ventilation while requiring decreasing amounts of oxygen, indicating improvement in the condition and successful treatment.

Answer 187

A) The patient should remain free of complications, maintain hemodynamic stability, and reduce oxygen requirements. Rationale: The appropriate goal for nursing care in ARDS is for the patient to remain free of complications, maintain hemodynamic stability, and require decreasing amounts of oxygen, which demonstrates the effectiveness of treatment and improving condition.

Answer 188

a. dyspnea and tachypnea.

Answer 189

a. prone positioning. c. low tidal volume ventilation. e. positive end expiratory pressure (PEEP).

Answer 190

c. Use of low tidal volume ventilation

Answer 191

a. Vancomycin (Vancocin) Rationale: 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.

Answer 192

d. Inserting a pulmonary artery catheter Rationale: 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.

Answer 193

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

Answer 194

b. “PEEP prevents the lung air sacs from collapsing during exhalation.” Rationale: 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 (FIO 2 ) delivered to the patient.

Answer 195

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

Answer 196

c. Obtain oxygen saturation using pulse oximetry. 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. 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.

Answer 197

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

Answer 198

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

Answer 199

c. Oxygen saturation 90% on 100% O2 by non-rebreather mask Rationale: 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 flow flowrate.

Answer 200

a. O2 saturation of 99% Rationale: 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 provider.

Answer 201

a. Red-brown drainage from nasogastric tube Rationale: 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.

Ch 32: Acute Respiratory Distress Syndrome (ARDS) Flashcards

(225 cards)