CH 32: Acute Respiratory Failure (ARF) Flashcards

Question

A patient with pneumonia has V/Q mismatch due to alveolar secretions. What is the best initial intervention? A. Heparin infusion B. Diuretic administration C. Chest physiotherapy D. Oxygen therapy

Answer 1

D. Oxygen therapy Rationale: Oxygen therapy is the first-line intervention for hypoxemia due to V/Q mismatch, though the underlying cause (e.g., secretions) must also be treated.

Answer 2

D. Impaired perfusion distal to the embolism Rationale: A pulmonary embolism blocks blood flow to lung tissue, decreasing perfusion, while ventilation remains normal, resulting in a V/Q mismatch.

Answer 3

B. Restlessness and confusion Rationale: Hypoxemia from V/Q mismatch first manifests as restlessness, agitation, and confusion due to cerebral hypoxia.

Answer 4

D. Immediate administration of thrombolytics Rationale: Thrombolytics dissolve the clot, restoring pulmonary blood flow, thereby correcting the V/Q mismatch caused by decreased perfusion.

Answer 5

B. O2 cannot reach alveoli due to secretions Rationale: In pneumonia, secretions block alveolar ventilation, preventing oxygen from reaching perfused areas, leading to persistent hypoxemia despite O2 therapy.

Answer 6

A. Increase PaO2 to improve tissue oxygenation Rationale: The goal of oxygen therapy in V/Q mismatch is to increase PaO2, improving oxygen delivery to tissues.

Answer 7

A. Ventilation and perfusion are not equal Rationale: A V/Q mismatch occurs when ventilation and perfusion are imbalanced, leading to hypoxemia.

Answer 8

C. Encourage incentive spirometry Rationale: Incentive spirometry promotes deep breathing and lung expansion, reducing atelectasis, a key contributor to V/Q mismatch.

Answer 9

A. Decreased PaCO2 levels Rationale: Oxygen therapy may improve ventilation and lower PaCO2, especially if hyperventilation occurs.

Answer 10

D. Initiate positive-pressure ventilation Rationale: Positive-pressure ventilation helps reopen collapsed alveoli, improving oxygenation in atelectasis-related V/Q mismatch.

Answer 11

A. Atelectasis Rationale: Atelectasis due to shallow breathing is a common cause of V/Q mismatch in post-operative patients.

Answer 12

B. Blood bypasses ventilated alveoli without participating in gas exchange Rationale: A pulmonary capillary shunt occurs when blood passes through pulmonary capillaries without participating in gas exchange due to alveolar filling (e.g., pneumonia, pulmonary edema). Unlike V/Q mismatch, which responds to oxygen therapy, a shunt does not because alveoli are completely filled with fluid, preventing oxygen diffusion into the bloodstream.

Answer 13

B. Ventricular septal defect Rationale: An anatomic shunt occurs when blood bypasses the lungs completely, such as in congenital heart defects like a VSD, where deoxygenated blood is shunted from the right to left heart without undergoing pulmonary gas exchange. This type of hypoxemia does not improve with oxygen therapy because the affected blood never reaches the alveoli. Unlike V/Q mismatch, which responds to oxygen therapy, an anatomic shunt requires surgical intervention.

Answer 14

C. To reopen collapsed alveoli and improve gas exchange Rationale: ARDS leads to a capillary shunt because fluid-filled alveoli prevent oxygenation. Positive end-expiratory pressure (PEEP) helps to keep alveoli open, recruit collapsed alveoli, and improve oxygen diffusion. Without PEEP, blood continues passing through non-ventilated alveoli, worsening shunting and leading to refractory hypoxemia. Oxygen therapy alone is ineffective in shunt-related hypoxemia, making PEEP essential.

Answer 15

C. A patient with lobar pneumonia and diffuse alveolar consolidation Rationale: A capillary shunt occurs when alveoli are completely filled with fluid, preventing gas exchange. Lobar pneumonia leads to extensive alveolar consolidation, meaning oxygen cannot diffuse across the alveolar-capillary membrane, resulting in refractory hypoxemia. This differs from V/Q mismatch, where ventilation is only partially impaired and responds to oxygen therapy.

Answer 16

D. Increased alveolar recruitment and improved oxygenation Rationale: High PEEP is crucial in treating shunt-related hypoxemia because it helps reopen collapsed alveoli, improving oxygenation in ARDS. Unlike V/Q mismatch, shunt-related hypoxemia does not respond to supplemental oxygen alone. Without PEEP, blood continues to bypass ventilated alveoli, worsening hypoxemia.

Answer 17

D. Chest x-ray showing alveolar infiltrates Rationale: A capillary shunt in pneumonia occurs because fluid-filled alveoli prevent oxygen diffusion, leading to refractory hypoxemia. A chest x-ray would show consolidation and infiltrates, confirming alveolar filling as the cause. Unlike V/Q mismatch, where oxygen therapy helps, a shunt requires mechanical ventilation to restore gas exchange.

Answer 18

A. Increase PEEP to improve alveolar recruitment Rationale: In ARDS, shunting occurs when alveoli collapse or fill with fluid, preventing oxygenation. Increasing PEEP keeps alveoli open, allowing oxygen diffusion to improve PaO₂ levels. Oxygen therapy alone does not correct hypoxemia caused by a shunt, making PEEP a necessary intervention.

Answer 19

A. Surgical correction of the cardiac defect Rationale: An anatomic shunt occurs when blood bypasses the lungs entirely, such as in congenital heart defects (e.g., ventricular septal defect). Since the affected blood never reaches ventilated alveoli, oxygen therapy is ineffective. The only definitive treatment is surgical correction to restore normal circulation and oxygenation.

Answer 20

B. Decreased time for oxygen diffusion due to increased cardiac output Rationale: Diffusion impairment worsens with exercise because increased cardiac output (CO) accelerates blood flow through the pulmonary capillaries, reducing the time available for oxygen diffusion. In pulmonary fibrosis, the thickened alveolar-capillary membrane already slows oxygen diffusion, and rapid blood flow exacerbates hypoxemia. Unlike V/Q mismatch, which responds to oxygen therapy, diffusion impairment requires interventions that improve oxygenation efficiency, such as pulmonary rehabilitation and supplemental oxygen.

Answer 21

B. Impaired gas exchange due to alveolar-capillary membrane thickening Rationale: ARDS leads to diffuse alveolar damage, causing fibrosis and thickening of the alveolar-capillary membrane, which slows oxygen diffusion. Even with high FiO₂, oxygen transport remains impaired, resulting in persistent hypoxemia. Unlike V/Q mismatch, where ventilation and perfusion are imbalanced, diffusion impairment is due to structural changes in the alveolar membrane, making oxygen therapy alone ineffective.

Answer 22

C. Pulmonary function test (PFT) with diffusion capacity of carbon monoxide (DLCO) Rationale: DLCO measures how well oxygen and carbon monoxide diffuse across the alveolar-capillary membrane. In diffusion impairment disorders (e.g., pulmonary fibrosis, ILD), DLCO is decreased due to thickened alveolar walls. Unlike ABGs, which assess current gas exchange, DLCO directly measures diffusion capacity, making it the most specific test for diagnosing diffusion impairment.

Answer 23

D. Worsening hypoxemia with exercise but normal oxygenation at rest Rationale: A hallmark of diffusion impairment is hypoxemia that worsens with exertion but remains stable at rest. During exercise, cardiac output increases, accelerating pulmonary blood flow and reducing the time available for oxygen diffusion across the thickened alveolar-capillary membrane. Unlike V/Q mismatch, which can occur at rest, diffusion impairment is most evident during increased circulatory demand.

Answer 24

D. A patient with pulmonary fibrosis and chronic hypoxemia Rationale: Pulmonary fibrosis leads to thickening and scarring of the alveolar-capillary membrane, which slows oxygen diffusion and causes progressive hypoxemia. This is the primary mechanism of diffusion impairment. Unlike COPD and asthma, which are primarily obstructive diseases affecting airway resistance, pulmonary fibrosis specifically disrupts the gas exchange surface, making it the most likely cause of diffusion impairment.

Answer 25

A. Rapid blood flow through the pulmonary capillaries reduces oxygen diffusion time Rationale: In high-output heart failure, cardiac output is excessively high, leading to rapid circulation through the lungs. This reduces the time for oxygen diffusion across the alveolar-capillary membrane, causing exercise-induced hypoxemia. Unlike pulmonary edema, which involves fluid accumulation, this form of diffusion impairment is related to circulation speed rather than alveolar obstruction.

Answer 26

B. Fluid accumulation in the alveoli increases the diffusion distance for oxygen Rationale: Pulmonary edema results in fluid accumulation in the alveoli, which increases the distance oxygen must travel to reach the bloodstream, slowing diffusion and causing hypoxemia. Unlike V/Q mismatch, which affects ventilation-perfusion balance, diffusion impairment is due to a physical barrier (fluid, protein, or inflammatory cells) preventing normal oxygen exchange.

Answer 27

C. Supplemental oxygen therapy Rationale: In diffusion impairment disorders, increasing FiO₂ improves the pressure gradient for oxygen diffusion, enhancing oxygenation despite the thickened alveolar-capillary membrane. While NIPPV may help in some cases, the primary intervention for diffusion impairment is supplemental oxygen.

Answer 28

D. Low-intensity exercise with oxygen supplementation Rationale: Exercise increases cardiac output, worsening diffusion impairment. However, low-intensity exercise with oxygen therapy can improve functional status while preventing severe desaturation. Avoiding exercise entirely leads to deconditioning, worsening respiratory function over time.

Answer 29

D. Serial pulmonary function tests with DLCO measurements Rationale: DLCO specifically measures diffusion capacity, making it the best indicator of disease progression in pulmonary fibrosis. Unlike peak flow, which assesses airway obstruction, DLCO directly evaluates alveolar-capillary membrane function.

Answer 30

A. Decreased lung compliance, limiting effective ventilation Rationale: Restrictive lung disease leads to decreased lung compliance, which limits the expansion of the lungs and reduces effective ventilation. As a result, alveolar hypoventilation occurs, causing increased PaCO₂. Unlike conditions causing increased airway resistance (e.g., asthma), restrictive lung disease primarily impairs the lung’s ability to expand, preventing adequate ventilation and contributing to hypercapnia.

Answer 31

A. Airway obstruction causing reduced ventilation and air trapping Rationale: In acute asthma, bronchoconstriction and airway inflammation cause airway obstruction, leading to reduced ventilation and air trapping. This results in hypoventilation and hypercapnia, as inadequate gas exchange occurs in the obstructed airways. Unlike restrictive lung diseases, asthma primarily causes airway obstruction rather than issues with lung compliance.

Answer 32

B. Impaired respiratory drive due to CNS dysfunction Rationale: CNS disorders can impair the respiratory centers in the brain, resulting in hypoventilation and hypercapnia. This occurs because the brain fails to adequately stimulate the respiratory muscles, leading to decreased ventilation and increased PaCO₂. Unlike conditions affecting lung compliance or airway resistance, CNS dysfunction directly affects the neural control of respiration.

Answer 33

C. Reduced chest wall expansion, limiting ventilation volume Rationale: Chest wall dysfunction (e.g., rib fractures or neuromuscular disease) impairs the mechanical ability to expand the chest during breathing. This limits ventilation volume, leading to alveolar hypoventilation and increased PaCO₂. Unlike conditions like pulmonary embolism or fluid accumulation, chest wall dysfunction directly restricts the ability to effectively move air into the lungs, contributing to hypercapnia.

Answer 34

D. V/Q mismatch and shunt Rationale: In pneumonia, inflammation, edema, and exudate can cause V/Q mismatch and shunt. V/Q mismatch occurs when airways are obstructed by inflammation or exudate, preventing adequate ventilation in some areas of the lung. Simultaneously, shunt occurs when fluid-filled alveoli impair gas exchange, leading to unoxygenated blood returning to the left side of the heart. These mechanisms together contribute to acute hypoxemic respiratory failure.

Answer 35

A. Increased O2 demand further exacerbates hypoxemia Rationale: Anxiety and unrelieved pain increase oxygen demand by elevating the metabolic rate and increasing sympathetic nervous system activity, which can lead to increased respiratory rate and heart rate. This further exacerbates hypoxemia by increasing the oxygen requirements without improving ventilation or perfusion. Unlike the other options, the body cannot meet this increased oxygen demand in the presence of ARF, leading to worsening respiratory failure.

Answer 36

A. Shunt prevents oxygen from reaching the pulmonary capillaries for gas exchange Rationale: Shunt occurs when blood bypasses the lungs and does not participate in gas exchange. Oxygen therapy alone is ineffective in improving PaO₂ in patients with shunt because the unoxygenated blood cannot be oxygenated. V/Q mismatch, on the other hand, can often be improved with supplemental oxygen, but shunt leads to persistent hypoxemia despite increased oxygen levels in the air.

Answer 37

C. Anxiety increases metabolic demand, worsening oxygenation Rationale: Anxiety increases sympathetic nervous system activity, leading to higher metabolic demand for oxygen, which worsens the already compromised oxygenation in ARF. As the patient’s body tries to meet this increased oxygen demand, it cannot do so due to impaired gas exchange

Answer 38

B. Cellular shift from aerobic to anaerobic metabolism, leading to lactic acid production Rationale: When hypoxia occurs, cells shift from aerobic to anaerobic metabolism to meet energy demands. Anaerobic metabolism produces lactic acid, which is less efficient and results in the accumulation of waste products. This accumulation of lactic acid is problematic because it leads to metabolic acidosis. Left untreated, the body’s ability to clear lactic acid diminishes, worsening tissue and cellular function.

Answer 39

B. Reduction in oxygen supply to mitochondria, impairing cellular function Rationale: In the presence of hypoxia, oxygen supply to mitochondria is reduced, impairing the normal cellular processes that depend on aerobic metabolism. This leads to a shift to anaerobic metabolism, which is less efficient and results in the production of lactic acid. This acid buildup causes metabolic acidosis and disrupts normal cellular function.

Answer 40

D. Production of lactic acid, leading to metabolic acidosis Rationale: Anaerobic metabolism is less efficient than aerobic metabolism, and its byproduct is lactic acid. The accumulation of lactic acid in the body leads to metabolic acidosis, as the body struggles to buffer and remove the acid. This is a critical consequence of hypoxia that exacerbates cellular dysfunction.

Answer 41

B. Altered enzyme function and cellular disruption Rationale: Metabolic acidosis from lactic acid buildup can disrupt enzyme function and compromise cellular function. This is because acidotic conditions can alter the activity of enzymes, leading to a breakdown of normal cellular processes and tissue dysfunction. Without treatment, these changes can progress to cell death.

Answer 42

C. Increased respiratory rate and shallow breathing Rationale: In response to hypoxia and metabolic acidosis, the body tries to compensate by increasing the respiratory rate to remove CO2 and buffer lactic acid. However, the patient may also demonstrate shallow breathing due to decreased lung compliance and fatigue. This leads to inadequate oxygenation, worsening the condition.

Answer 43

D. Lactic acid must be buffered with sodium bicarbonate, which can lead to metabolic acidosis Rationale: Lactic acid is a byproduct of anaerobic metabolism and must be buffered with sodium bicarbonate in the body. If there is insufficient sodium bicarbonate to neutralize the acid, metabolic acidosis occurs. This worsens the patient’s condition, leading to further cellular dysfunction and, if left untreated, cell death.

Answer 44

B. Tissue and cellular dysfunction progressing to cell death Rationale: If hypoxemia progresses to severe hypoxia, cells begin to rely on anaerobic metabolism, leading to the accumulation of lactic acid and metabolic acidosis. This disrupts normal cellular processes, resulting in tissue and cellular dysfunction. Without correction, this process can ultimately lead to cell death, organ failure, and systemic collapse.

Answer 45

A. Increased CO2 production or decreased alveolar ventilation Rationale: Acute hypercapnic respiratory failure occurs when the respiratory system cannot maintain normal CO2 levels due to increased CO2 production or decreased alveolar ventilation. The body’s inability to eliminate CO2 efficiently results in a buildup of CO2 in the bloodstream, leading to respiratory acidosis and impaired cellular function.

Answer 46

D. Impaired respiratory drive from conditions like drug overdose or brain injury Rationale: CNS problems such as drug overdose or brain injury can impair the brain’s ability to regulate the respiratory drive. This can decrease the body’s ability to stimulate appropriate ventilation, leading to hypercapnic respiratory failure. Conditions that reduce respiratory drive or affect the brainstem can hinder the body’s ability to expel CO2 properly.

Answer 47

D. Myasthenia gravis causing muscle weakness and impaired breathing Rationale: Neuromuscular problems like myasthenia gravis can impair the strength and function of respiratory muscles, including the diaphragm, leading to hypercapnic respiratory failure. The resulting weakness of respiratory muscles impairs the ability to ventilate the lungs effectively, preventing adequate elimination of CO2 from the body.

Answer 48

C. Kyphoscoliosis restricting chest expansion Rationale: Chest wall abnormalities, such as kyphoscoliosis, can severely restrict the expansion of the chest wall and lungs, limiting the ability to take deep breaths and effectively ventilate. This restriction leads to decreased alveolar ventilation, contributing to hypercapnic respiratory failure.

Answer 49

A. Increased pCO2 levels and decreased oxygenation Rationale: In hypercapnic respiratory failure, the primary issue is the inability to eliminate CO2 effectively, leading to an increase in pCO2 levels (respiratory acidosis). This impaired ventilation often also leads to decreased oxygenation, as the body cannot adequately exchange gases. Consequently, hypoxemia often accompanies hypercapnia.

Answer 50

D. Impaired ventilatory effort due to neuromuscular or CNS issues Rationale: In patients with normal lung function, hypercapnic respiratory failure is most often caused by neuromuscular or CNS problems that impair the ventilatory effort. Conditions such as neuromuscular diseases (e.g., myasthenia gravis) or CNS dysfunction (e.g., brain injury or drug overdose) can reduce the ability of the respiratory muscles to function properly, leading to ventilatory failure and elevated CO2 levels.

Answer 51

B. Decreased CO2 reactivity in the brainstem due to opioid use Rationale: Opioids are central nervous system depressants that decrease CO2 reactivity in the brainstem. This reduces the ability of the brainstem to detect increased CO2 levels in the blood, impairing the respiratory drive and leading to hypoventilation. As a result, CO2 levels rise, contributing to hypercapnic respiratory failure.

Answer 52

C. Decreased respiratory rate with elevated PaCO2 levels Rationale: TBI can impair the function of the medullary respiratory center, which leads to a decreased ability to sense increased PaCO2 levels. This results in a decreased respiratory rate despite elevated PaCO2. This hypoventilation contributes to hypercapnic respiratory failure by preventing effective CO2 elimination.

Answer 53

A. Damage to the phrenic nerve leading to impaired diaphragm function Rationale: A high-level SCI can disrupt the phrenic nerve, which controls the diaphragm. Without adequate diaphragm function, the patient may struggle with effective ventilation, leading to hypercapnic respiratory failure. This is because the diaphragm is critical for inhalation and exhalation, and damage to the nerve impairs this process, preventing adequate CO2 elimination.

Answer 54

D. Impaired ability to regulate respiratory rate in response to PaCO2 changes Rationale: A brainstem infarction can impair the function of the respiratory centers in the medulla, which are responsible for regulating the respiratory rate in response to changes in PaCO2. This leads to a decreased respiratory drive and the inability to appropriately increase the rate of breathing in response to elevated CO2 levels, contributing to hypercapnic respiratory failure.

Answer 55

A. Impaired ability to clear secretions and protect the airway Rationale: A patient with TBI and a decreased level of consciousness is at risk for aspiration and airway obstruction due to impaired cough reflex and inability to clear secretions. This increases the risk for respiratory failure, as blocked airways can impair gas exchange, leading to both hypoxemia and hypercapnia. Protecting the airway and ensuring proper ventilation are crucial for these patients.

Answer 56

D. Administration of naloxone to reverse the effects of the opioid Rationale: Naloxone, an opioid antagonist, is used to reverse the CNS depression caused by opioid overdose. By blocking the effects of the opioid on the brainstem, naloxone restores the respiratory drive, which is essential for the patient to regain normal ventilation and eliminate CO2 effectively, thus addressing the hypercapnic respiratory failure.

Answer 57

A. Severe brain edema leading to compression of respiratory centers Rationale: Severe brain edema following TBI can lead to compression of the respiratory centers in the brainstem, impeding the brain’s ability to detect changes in PaCO2 and regulate ventilation accordingly. This results in hypoventilation, which prevents proper CO2 elimination, leading to hypercapnic respiratory failure.

Answer 58

A. Impaired ventilation due to respiratory muscle paralysis Rationale: Guillain-Barré syndrome causes ascending paralysis, which affects the respiratory muscles, including the diaphragm and intercostal muscles. As these muscles become weak or paralyzed, the patient cannot effectively ventilate the lungs, leading to an inability to eliminate CO2, which results in hypercapnic respiratory failure.

Answer 59

B. Weakening of respiratory muscles and ineffective ventilation Rationale: Multiple sclerosis (MS) can cause muscle weakness, including respiratory muscles, which can impair the ability to ventilate effectively. As respiratory muscles weaken, the patient is at risk for hypoventilation, leading to the accumulation of CO2 and hypercapnic respiratory failure. Monitoring for respiratory muscle weakness and the ability to clear CO2 is critical in this patient population.

Answer 60

B. Impaired nerve supply to the respiratory muscles, leading to ineffective ventilation Rationale: Peripheral nerve damage can disrupt the communication between the central nervous system and the respiratory muscles. This impairs the ability of the muscles to contract and function effectively, leading to ineffective ventilation. As a result, CO2 is not eliminated adequately, causing hypercapnic respiratory failure.

Answer 61

A. Chemical agents causing respiratory muscle paralysis through disruption of nerve function Rationale: Chemical nerve agents, such as organophosphates, interfere with the nerve supply to respiratory muscles, causing muscle paralysis. This paralysis prevents adequate ventilation and the ability to clear CO2 from the lungs, leading to hypercapnic respiratory failure.

Answer 62

C. Assessing respiratory muscle strength and ventilatory function Rationale: Muscle wasting in critically ill patients can lead to respiratory muscle weakness, increasing the risk for respiratory failure. It is essential to assess respiratory muscle strength and monitor ventilatory function to detect early signs of hypoventilation and prevent hypercapnic respiratory failure. If muscle weakness is severe, mechanical ventilation may be required to support breathing.

Answer 63

D. Excessive weight on the chest and abdominal contents limits lung expansion Rationale: Severe obesity restricts lung expansion due to the increased weight of the chest and abdominal contents, particularly the abdomen, which presses up against the diaphragm. This decreases the available lung volume for gas exchange, increasing the risk of hypoventilation and ventilatory failure. The reduced expansion limits the ability to inhale deeply, which can result in poor oxygenation and hypercapnia.

Answer 64

D. Paradoxical chest movement during respiration Rationale: In flail chest, the rib fractures prevent normal chest expansion. The fractured segment of the chest wall moves paradoxically—it moves inward during inspiration and outward during expiration, opposite to the normal chest wall movement. This impairs ventilation and increases the work of breathing, contributing to hypoventilation and the risk of respiratory failure.

Answer 65

A. Spinal compression prevents normal lung expansion Rationale: Kyphosis causes a change in spinal configuration that compresses the lungs, restricting chest wall expansion and reducing the ability of the lungs to expand fully during inspiration. This leads to impaired ventilation and hypoventilation, resulting in respiratory failure. The decreased lung expansion reduces the volume of air that can be inhaled, which contributes to hypoxemia and hypercapnia.

Answer 66

B. Use of accessory muscles with shallow breathing Rationale: In severe obesity, the increased weight of the chest and abdominal contents can limit lung expansion. As a result, the patient may have shallow breathing and need to use accessory muscles to aid in ventilation. This increased work of breathing is a sign of respiratory distress and hypoventilation, indicating that the patient may be at risk for ventilatory failure. The inability to take deep breaths leads to insufficient gas exchange and possible hypoxemia and hypercapnia.

Answer 67

A. Increased airway resistance and air trapping in the alveoli Rationale: In COPD, airway obstruction and air trapping in the alveoli occur due to chronic inflammation and narrowing of the airways. This leads to increased work of breathing and difficulty exhaling air from the lungs, which contributes to hypercapnia. The added work of breathing results in respiratory muscle fatigue and can ultimately lead to ventilatory failure, making it difficult for the patient to maintain adequate CO2 levels.

Answer 68

C. Airway obstruction and air trapping, increasing the work of breathing Rationale: In asthma, bronchospasm causes airway obstruction, which leads to air trapping in the lungs. The increased work of breathing (WOB) required to inspire air against increased airway resistance causes ventilatory failure. Over time, the patient may experience respiratory muscle fatigue as the muscles are overworked, resulting in hypercapnic respiratory failure due to the inability to effectively exhale CO2.

Answer 69

B. Impaired gas exchange due to thick mucus obstructing the airways Rationale: In cystic fibrosis, the accumulation of thick mucus in the airways leads to airway obstruction and impaired gas exchange. The mucus plugs block the flow of air and reduce the ability to exhale CO2, leading to hypercapnia. This significantly increases the work of breathing and can cause respiratory muscle fatigue, which eventually results in ventilatory failure.

Answer 70

D. Increased airway resistance and inability to adequately exhale air Rationale: In COPD, there is increased airway resistance and air trapping in the lungs, which makes it difficult for the patient to exhale air effectively. This leads to an accumulation of CO2 in the blood, resulting in hypercapnic respiratory failure. Even with supplemental oxygen, if the patient cannot adequately exhale due to obstructed airways, respiratory muscle fatigue may occur, worsening the ventilatory failure. Oxygen therapy alone will not correct the underlying issue of airway obstruction.

Answer 71

A. Retention of bicarbonate by the kidneys Rationale: In cases of chronic hypercapnia, such as in COPD, the kidneys compensate by retaining bicarbonate (HCO3-) to buffer the excess CO2 in the blood. This compensatory mechanism helps maintain pH balance in the body by minimizing the acidic effects of increased CO2. This compensation occurs gradually, allowing the body to adapt to slow increases in PaCO2. Without treatment for the underlying cause, however, the patient may continue to worsen as the compensatory mechanisms reach their limit.

Answer 72

C. The body has more efficient mechanisms to compensate for CO2 retention Rationale: The body is generally more capable of compensating for increased CO2 levels than decreased oxygen levels. This is because slow, steady increases in PaCO2 allow the body time to compensate, mainly through renal retention of bicarbonate to buffer the acidity. On the other hand, hypoxemia (low O2 levels) does not have as much time to trigger compensatory mechanisms and can lead to more immediate and severe cellular dysfunction.

Answer 73

C. Retention of bicarbonate to buffer the excess CO2 and maintain pH Rationale: When the body experiences chronic hypercapnia, such as in COPD, the kidneys compensate by retaining bicarbonate to buffer the excess CO2 and minimize changes in the arterial pH. This process helps maintain acid-base balance in the body and prevents the development of severe acidosis. Without correcting the underlying cause of the hypercapnia (e.g., the infection), however, this compensatory mechanism may eventually fail.

Answer 74

C. Identifying and treating the underlying cause of hypercapnia Rationale: While oxygen therapy may help improve oxygenation in patients with hypercapnia, the most effective intervention is to identify and treat the underlying cause (e.g., infection, inflammation, or obstruction). Treating the primary cause of hypercapnia allows for correction of the condition, thus preventing worsening respiratory failure. In the case of COPD, treating the infection or inflammation would help alleviate the increased CO2 levels.

Answer 75

D. The kidneys retain bicarbonate to buffer excess CO2, preventing severe acidosis Rationale: In response to chronic hypercapnia, such as in COPD, the kidneys compensate by retaining bicarbonate (HCO3-), which helps to buffer the excess CO2 and maintain a normal pH. This slow adjustment allows the body to tolerate higher levels of CO2 without immediate effects of acidosis. However, if the underlying cause is not treated, these compensatory mechanisms may eventually be overwhelmed, leading to respiratory failure.

Answer 76

D. The patient may experience worsening respiratory failure and tissue hypoxia Rationale: In chronic hypercapnia, such as in COPD, the body can initially compensate for increased CO2 by retaining bicarbonate to buffer the acid. However, if the underlying cause is not corrected (e.g., the upper respiratory infection), the patient may progress to worsening respiratory failure. Hypoxia and tissue dysfunction can occur as the body’s compensatory mechanisms become overwhelmed, leading to a decrease in oxygen supply to tissues. The risk of respiratory failure increases as the body cannot compensate effectively without treatment.

Answer 77

A. V/Q mismatch and shunting Rationale: Pulmonary embolism commonly causes hypoxemic respiratory failure due to V/Q mismatch and shunting. The embolism obstructs pulmonary circulation, causing mismatched ventilation and perfusion, which leads to hypoxemia. Unlike hypercapnic failure, the issue in hypoxemic failure is primarily oxygenation, not CO2 retention.

Answer 78

C. Airflow obstruction and air trapping Rationale: In chronic bronchitis, airflow obstruction and air trapping due to increased mucus production and bronchial inflammation are the primary mechanisms causing hypercapnic respiratory failure. This results in ventilatory failure where the body cannot adequately eliminate CO2.

Answer 79

A. V/Q mismatch and shunting from alveolar consolidation Rationale: In pneumonia, alveolar consolidation can lead to V/Q mismatch and shunting, preventing proper gas exchange and causing hypoxemic respiratory failure. Air trapping and hypercapnia are typically seen in obstructive lung diseases like COPD rather than in pneumonia.

Answer 80

C. A 45-year-old patient with severe obesity Rationale: Severe obesity can lead to hypoventilation syndrome, where the overweight chest wall impairs lung expansion, making it difficult to eliminate CO2, leading to hypercapnic respiratory failure. While pulmonary embolism, pneumonia, and acute asthma are more commonly associated with hypoxemic respiratory failure, obesity is a primary risk factor for hypercapnia.

Answer 81

D. Fluid accumulation in the alveoli impairing gas exchange Rationale: In pulmonary edema, fluid accumulation in the alveoli interferes with gas exchange, leading to hypoxemic respiratory failure. This condition impairs the ability of oxygen to diffuse into the bloodstream and results in hypoxia. It does not primarily involve airway obstruction or CO2 retention as seen in hypercapnic failure.

Answer 82

D. Increased work of breathing due to airflow obstruction Rationale: In COPD, airflow obstruction causes increased work of breathing, which can lead to hypercapnic respiratory failure because the patient cannot adequately eliminate CO2. This is not due to impaired surfactant production or increased alveolar perfusion but rather the increased effort required to breathe against the obstructed airways.

Answer 83

B. Weakness of respiratory muscles impeding CO2 elimination Rationale: In neuromuscular diseases such as Guillain-Barré syndrome or amyotrophic lateral sclerosis (ALS), weakness of the respiratory muscles impairs the ability to ventilate and eliminate CO2, leading to hypercapnic respiratory failure. This differs from conditions that primarily affect oxygen diffusion or airway patency.

Answer 84

A. V/Q mismatch due to alveolar consolidation Rationale: Pneumonia typically causes hypoxemic respiratory failure due to V/Q mismatch, where consolidation in the alveoli impairs gas exchange. This results in hypoxemia. It does not primarily cause hypercapnia or airway obstruction, which are associated with other conditions.

Answer 85

C. Impaired chest wall expansion leading to reduced ventilation Rationale: Kyphoscoliosis causes abnormal spinal curvature, which limits chest wall expansion and impairs lung ventilation. This leads to hypoventilation and can contribute to respiratory failure. It does not directly involve airway obstruction, shunting, or loss of CNS respiratory drive.

Answer 86

A. Impaired ventilation and V/Q mismatch due to lung collapse Rationale: Pneumothorax causes a collapse of the lung, impairing ventilation and leading to V/Q mismatch, which causes hypoxemic respiratory failure. This condition does not primarily result from CO2 retention or changes in alveolar perfusion.

Answer 87

D. Weakness of respiratory muscles leading to inadequate ventilation Rationale: Muscular dystrophy leads to weakness of respiratory muscles, which impairs the ability to ventilate effectively and eliminate CO2, leading to hypercapnic respiratory failure.

Answer 88

B. V/Q mismatch and fluid accumulation in alveoli Rationale: In pulmonary edema, fluid accumulates in the alveoli, impairing gas exchange and leading to V/Q mismatch, which is the primary cause of hypoxemic respiratory failure. The condition does not primarily involve increased CO2 production or airway obstruction.

Answer 89

D. Promoting weight loss and using CPAP Rationale: In patients with severe obesity, hypoventilation syndrome can lead to hypercapnic respiratory failure. Continuous positive airway pressure (CPAP) helps improve ventilation and promoting weight loss can help reduce the risk of further respiratory issues. Simply using high-flow oxygen or encouraging back sleeping are not the most effective interventions for this specific condition.

Answer 90

B. Weakness of respiratory muscles affecting CO2 elimination Rationale: In neuromuscular diseases, weakness of respiratory muscles impairs the ability to adequately ventilate and eliminate CO2, leading to hypercapnic respiratory failure. This is distinct from conditions involving airway resistance or decreased alveolar perfusion, which are not typically the cause of hypercapnia in neuromuscular diseases.

Answer 91

B. Severe respiratory compromise requiring urgent intervention Rationale: A rapid rise in PaCO2 suggests severe respiratory compromise, as the body cannot effectively eliminate CO2. This indicates the need for urgent intervention to address the underlying cause of respiratory failure and prevent life-threatening complications.

Answer 92

A. Respiratory muscle fatigue and acidemia Rationale: Severe bronchospasm in asthma leads to respiratory muscle fatigue due to the increased effort required to breathe. This, combined with impaired airflow, causes acidemia and can result in acute respiratory failure (ARF).

Answer 93

C. Restlessness, confusion, and agitation Rationale: Mental status changes, such as restlessness, confusion, and agitation, are often the first signs of hypoxemic ARF due to inadequate oxygenation of the brain. These signs typically occur before more severe manifestations, such as cyanosis.

Answer 94

C. Cyanosis and low oxygen saturation Rationale: Cyanosis and low oxygen saturation are late signs of respiratory failure, indicating that the body’s compensatory mechanisms have failed to maintain adequate oxygenation. Tachycardia and tachypnea are early compensatory responses that occur before these more severe signs.

Answer 95

B. Attempts by the body to increase oxygen delivery Rationale: Tachypnea and tachycardia are compensatory responses aimed at increasing oxygen delivery and eliminating CO2. These are early signs of respiratory failure as the body tries to compensate for declining oxygen levels and rising CO2.

Answer 96

C. Increased respiratory rate Rationale: In the early stages of ARF, the body compensates for hypoxia by increasing the respiratory rate to enhance oxygen intake. Cyanosis is a late sign of ARF and does not occur until oxygen levels are critically low.

Answer 97

B. Cyanosis Rationale: Cyanosis is a late sign of hypoxemia and is often unreliable as an early indicator of ARF. It typically does not appear until there is a significant decrease in oxygen saturation, often when deoxygenated hemoglobin concentration is around 5 g/dL.

Answer 98

D. Restlessness, agitation, and decreased O2 saturation Rationale: Restlessness and agitation in conjunction with decreased oxygen saturation indicate severe hypoxia and impaired oxygen delivery to the brain. This requires immediate intervention to prevent further deterioration and complications.

Answer 99

A. Increase the anteroposterior diameter of the chest Rationale: The tripod position is commonly used by patients with severe respiratory distress to increase the anteroposterior chest diameter, which helps to reduce the work of breathing (WOB) and improve ventilation. It is particularly beneficial for patients with COPD.

Answer 100

B. The patient is sitting with arms propped on the knees or table Rationale: In the tripod position, the patient sits upright with arms propped on the knees or an overbed table. This position helps to increase chest diameter and decrease thoracic pressure, easing the work of breathing (WOB) in patients with severe respiratory distress.

Answer 101

C. V/Q mismatch and impaired gas exchange Rationale: In pneumonia, inflammation and exudate in the alveoli lead to V/Q mismatch, where ventilation and perfusion are not balanced, causing impaired gas exchange and resulting in hypoxemic respiratory failure.

Answer 102

A. Hypoxia and inadequate oxygenation Rationale: Restlessness and agitation are often early signs of hypoxia in patients with respiratory failure, indicating inadequate oxygen delivery to the brain. These symptoms warrant immediate intervention to prevent further deterioration.

Answer 103

B. Confusion and agitation associated with worsening dyspnea

Answer 104

A. Increased work of breathing and respiratory muscle fatigue Rationale: A rapid, shallow breathing pattern increases the work of breathing and can lead to respiratory muscle fatigue due to the high effort required for each breath, thus compromising the patient’s ability to effectively oxygenate and eliminate CO2.

Answer 105

B. Severe respiratory muscle fatigue and increased risk of respiratory arrest Rationale: A slower respiratory rate after initial rapid breathing in patients with acute asthma suggests severe respiratory muscle fatigue, which is an ominous sign of impending respiratory arrest due to the inability of the respiratory muscles to maintain adequate ventilation.

Answer 106

C. Moderate to severe respiratory distress with impaired oxygenation Rationale: “Two-word dyspnea” indicates that the patient is experiencing significant respiratory distress, with limited ability to speak due to impaired oxygenation. This signifies moderate to severe distress, requiring prompt intervention to prevent worsening.

Answer 107

A. Increases SaO2 by slowing respirations and preventing bronchiolar collapse Rationale: Pursed-lip breathing helps slow respiration and increases time for expiration, which prevents small bronchioles from collapsing. This technique improves SaO2 and reduces the work of breathing, which is helpful for patients with obstructive lung conditions like ARF.

Answer 108

B. Severe respiratory distress with increased work of breathing Rationale: Retraction of the intercostal spaces indicates the use of accessory muscles and suggests severe respiratory distress. It indicates an increased work of breathing (WOB) and requires immediate attention to prevent further deterioration.

Answer 109

C. Severe respiratory distress and maximal use of accessory muscles Rationale: Paradoxical breathing occurs in severe respiratory distress when the abdomen and chest move in opposite directions. This pattern results from maximal use of accessory muscles, indicating significant difficulty in breathing and a need for urgent intervention.

Answer 110

A. Hypercapnia and respiratory muscle fatigue Rationale: Diaphoresis in the context of increased work of breathing indicates hypercapnia (elevated CO2) and respiratory muscle fatigue, both of which can occur during acute respiratory failure as the body struggles to compensate for inadequate ventilation.

Answer 111

A. Pulmonary edema Rationale: Fine crackles are often heard in patients with pulmonary edema, indicating the presence of fluid in the alveoli. This can impair gas exchange and contribute to the development of acute respiratory failure.

Answer 112

A. Fluid in the airways, potentially due to pneumonia or heart failure Rationale: Coarse crackles on expiration are indicative of fluid in the airways, commonly associated with pneumonia or heart failure. This fluid impairs ventilation and can lead to hypoxemia and acute respiratory failure.

Answer 113

D. Consolidation of the lung tissue Rationale: Bronchial breath sounds heard over the periphery of the lungs are abnormal and typically indicate lung consolidation, which occurs in conditions like pneumonia, where alveolar spaces fill with fluid or exudate, leading to impaired gas exchange.

Answer 114

A. Infection involving the pleura, such as pneumonia Rationale: A pleural friction rub is often heard when the pleura is inflamed, as seen in pneumonia or other infections that involve the pleura. This sound occurs when the inflamed pleural layers rub against each other during respiration.

Answer 115

D. Paradoxical breathing pattern with increased WOB Rationale: Paradoxical breathing is a sign of severe respiratory distress and requires immediate intervention. It indicates maximal use of accessory muscles and a failure of normal respiratory mechanics, which can rapidly progress to respiratory failure.

Answer 116

A. Atelectasis, pleural effusion, or hypoventilation Rationale: Absent or decreased breath sounds in the lower lobes are often associated with atelectasis, pleural effusion, or hypoventilation. These conditions impair lung expansion and contribute to acute respiratory failure.

Answer 117

C. ABG analysis Rationale: ABG analysis is the most common diagnostic tool to evaluate both oxygenation (PaO2) and ventilation (PaCO2), as well as acid-base balance (pH and bicarbonate). This provides crucial information for assessing the severity of ARF.

Answer 118

B. Collapsed lung tissue, impairing gas exchange Rationale: Atelectasis refers to the collapse of lung tissue, leading to impaired gas exchange and potential development of ARF. This condition can obstruct airflow and compromise ventilation, causing hypoxemia.

Answer 119

C. Detect a pulmonary embolism or other blockages in the pulmonary vasculature Rationale: A CT scan is commonly used to detect a pulmonary embolism (PE), which can cause acute respiratory failure by blocking pulmonary blood flow. It is particularly helpful in identifying emboli that may not be visible on a chest x-ray.

Answer 120

A. End-tidal CO2 (EtCO2) measurement Rationale: End-tidal CO2 (EtCO2) is used to assess ventilation trends in patients requiring mechanical ventilation. It provides real-time feedback on how effectively CO2 is being eliminated from the body.

Answer 121

A. To identify the presence of a bacterial or viral infection Rationale: Blood and sputum cultures (including Gram stain, culture, and sensitivity) are used to identify infections, which are common causes of ARF. They help guide appropriate antibiotic therapy and address the underlying infectious cause.

Answer 122

B. Pulse oximetry Rationale: Pulse oximetry is a non-invasive and continuous method to monitor oxygen saturation (SaO2), providing real-time information about a patient’s oxygenation status. It is particularly useful for ongoing assessment in patients with ARF.

Answer 123

C. Hypoventilation and respiratory acidosis Rationale: Low PaO2 (indicating hypoxemia) and elevated PaCO2 (indicating hypoventilation) are characteristic of respiratory acidosis. This is commonly seen in ARF where ventilation is inadequate to eliminate CO2 and maintain oxygenation.

Answer 124

D. Elevated WBC count Rationale: An elevated white blood cell count (WBC) is a common indicator of infection, which may contribute to ARF. Infections such as pneumonia or sepsis can trigger the inflammatory response, leading to impaired ventilation and oxygenation.

Answer 125

B. Patient’s age and underlying comorbidities Rationale: The initial management of ARF is tailored based on patient-specific factors such as age, underlying comorbidities, and the severity and cause of respiratory failure. This allows for personalized treatment strategies that address the root cause and patient’s needs.

Answer 126

A. Non-invasive positive pressure ventilation Rationale: In patients with mild to moderate ARF, non-invasive positive pressure ventilation (e.g., BiPAP) may be used, especially if the patient is alert, able to maintain a patent airway, and can clear their own secretions. This method supports oxygenation and ventilation without the need for invasive intubation.

Answer 127

D. Pulse oximetry and ABG analysis Rationale: In severe ARF, monitoring of pulse oximetry and frequent ABG analysis is critical to assess oxygenation, ventilation, and acid-base balance. These parameters guide adjustments in mechanical ventilation and other treatments.

Answer 128

B. To assess the adequacy of tissue perfusion and response to treatment Rationale: Central venous O2 saturation (SvO2) provides information about tissue perfusion and the balance between oxygen delivery and consumption. It helps assess how well the body is responding to interventions aimed at improving oxygenation and circulation in ARF patients.

Answer 129

D. Oxygen saturation (SpO2) Rationale: While SpO2 is essential for monitoring oxygenation, ejection fraction, CVP, and PCWP are used to assess cardiac function and hemodynamics, particularly in patients with severe ARF requiring intensive care. Oxygen saturation (SpO2) is not specific to cardiac function.

Answer 130

A. Maintain a sterile environment around the intubation site Rationale: Maintaining a sterile environment around the intubation site is crucial to prevent ventilator-associated pneumonia and other infections. It is a priority for infection control in patients on mechanical ventilation.

Answer 131

A. Signs of oxygen toxicity and hypercapnia Rationale: High-flow oxygen therapy can potentially cause oxygen toxicity and hypercapnia, especially in patients with underlying COPD or other conditions that impair CO2 removal. Close monitoring for these complications is important.

Answer 132

D. Serum potassium levels Rationale: Advanced hemodynamic monitoring focuses on cardiac output (CO), pulmonary capillary wedge pressure (PCWP), and central venous oxygen saturation (SvO2) to assess circulatory status and tissue perfusion. Serum potassium levels are not part of this specific monitoring.

Answer 133

C. Ensure that oxygen delivery meets the patient’s metabolic demands Rationale: The primary goal of mechanical ventilation is to support the patient’s respiratory function by ensuring that oxygen delivery is adequate to meet the patient’s metabolic demands, especially in the context of ARF, where the lungs cannot maintain adequate gas exchange on their own.

Answer 134

A. Assessing the patient’s ability to maintain a patent airway and breathe Rationale: The priority assessment in a patient with ARF is to evaluate their ability to maintain a patent airway and adequate ventilation. This ensures that the patient is able to oxygenate properly and removes CO2, which is essential in managing respiratory failure.

Answer 135

A. Pulse oximetry and ABG trends Rationale: Pulse oximetry and ABG trends are critical tools for monitoring oxygenation and ventilation status, particularly in patients with preexisting cardiac and respiratory disease. Subtle changes in these parameters can indicate the onset of respiratory or hemodynamic decompensation.

Answer 136

C. Changes in level of consciousness Rationale: Changes in level of consciousness are a subtle sign of worsening hypoxemia or hypercarbia. This is because the brain is highly sensitive to changes in oxygen and carbon dioxide levels. Mental status changes such as restlessness, confusion, or agitation may indicate inadequate oxygen delivery to the brain.

Answer 137

B. Notify the healthcare provider (HCP) immediately Rationale: If subtle changes in pulse oximetry or ABGs suggest worsening respiratory failure, the nurse must notify the healthcare provider immediately to initiate timely interventions, prevent further deterioration, and improve patient outcomes.

Answer 138

B. Trend in ABGs and pulse oximetry Rationale: The trend in ABGs and pulse oximetry provides the best measure of the patient’s oxygenation and ventilation status, which is essential for evaluating their response to therapy and adjusting treatment accordingly.

Answer 139

C. Perform a thorough respiratory assessment including breath sounds Rationale: A thorough respiratory assessment, including auscultating breath sounds, helps in detecting early signs of respiratory insufficiency. This includes identifying abnormal sounds such as crackles or wheezes, which may indicate worsening conditions like pulmonary edema or bronchospasm.

Answer 140

A. Increase the oxygen delivery rate and assess the patient’s response Rationale: A sudden decrease in PaO2 suggests an acute respiratory problem, and the nurse should immediately increase the oxygen delivery rate while assessing the patient’s response to therapy. Prompt adjustments are necessary to prevent further deterioration.

Answer 141

B. Decreased PaO2 levels Rationale: A decreased PaO2 level indicates worsening hypoxemia, a key feature of acute respiratory failure. This is a critical change that requires immediate attention and intervention to restore adequate oxygenation.

Answer 142

C. Late manifestations of hypoxemia Rationale: Intercostal muscle retraction and nasal flaring are specific signs that indicate severe hypoxemia. These are often observed in late stages as the body struggles to maintain adequate oxygen levels.

Answer 143

B. Severe oxygen deprivation and impending respiratory failure Rationale: SpO2 levels below 90% indicate severe hypoxemia, which can lead to respiratory failure if not corrected promptly. This is a critical finding requiring immediate intervention.

Answer 144

A. Morning headache Rationale: A morning headache is a late manifestation of hypercapnia. It results from increased CO2 levels in the blood, which can lead to vasodilation and increased pressure in the cranial cavity.

Answer 145

C. Early signs of hypoxia affecting the central nervous system Rationale: Agitation, confusion, and restlessness are often early manifestations of hypoxia affecting the central nervous system (CNS). These symptoms reflect inadequate oxygen supply to the brain.

Answer 146

A. Hypercapnia Rationale: Tripod positioning and pursed-lip breathing are commonly observed in patients with hypercapnia as they attempt to facilitate better airflow and reduce the work of breathing, improving gas exchange.

Answer 147

D. Monitor the patient’s neurological status for further changes Rationale: Muscle weakness and tremors are neurological signs of hypercapnia. The nurse should continue to monitor for progression and ensure that the patient is closely observed for increased somnolence or coma, which are late signs of hypercapnia.

Answer 148

C. Compensatory response to decreased oxygen levels Rationale: Tachypnea and elevated BP are compensatory mechanisms in response to hypoxemia, as the body tries to increase oxygen intake and perfusion to vital organs. However, if the condition worsens, blood pressure may drop in the late stages.

Answer 149

C. Cyanosis and decreased level of consciousness Rationale: Cyanosis and decreased level of consciousness are late manifestations of hypoxemia, signifying severe oxygen deprivation. Immediate intervention is needed to prevent respiratory failure.

Answer 150

D. Progressive somnolence and increased ICP Rationale: Progressive somnolence and increased intracranial pressure (ICP) are late signs of hypercapnia, indicating worsening respiratory function and the risk of respiratory failure. These changes necessitate urgent intervention.

Answer 151

A. Hypercapnia and respiratory acidosis Rationale: Decreased tidal volume and shallow respirations are indicative of hypercapnia, which leads to respiratory acidosis due to insufficient CO2 removal. This can be a sign of respiratory failure.

Answer 152

A. Severe oxygen deprivation and shock Rationale: Cool, clammy, and diaphoretic skin is a sign of severe hypoxemia and the body’s attempt to compensate for inadequate oxygen supply. It also suggests that the patient may be entering shock.

Answer 153

B. Severe respiratory distress and impending failure Rationale: Paradoxical chest or abdominal wall movement is a late sign of severe respiratory distress and can occur when the patient’s respiratory muscles become fatigued and unable to maintain normal breathing patterns, indicating impending respiratory failure.

Answer 154

D. Increased cerebrovascular pressure due to elevated CO2 levels Rationale: Seizures in patients with hypercapnia are typically due to increased cerebrovascular pressure, as elevated CO2 levels can cause vasodilation of cerebral blood vessels, leading to increased intracranial pressure and neurological symptoms such as seizures.

Answer 155

B) The patient will independently maintain a patent airway. Rationale: The most important goal for a patient with ARF is to ensure that the patient can independently maintain a patent airway, as this is critical for preventing further respiratory compromise.

Answer 156

C) The patient will maintain a patent airway and restore baseline oxygenation levels. Rationale: The immediate priority for this patient is to maintain a patent airway and restore baseline oxygenation to prevent further deterioration. Other goals like controlled coughing or clearing secretions are important but secondary in this acute phase.

Answer 157

C) Monitoring the patient for signs of respiratory distress and providing supplemental oxygen as needed. Rationale: Monitoring for signs of respiratory distress and providing supplemental oxygen helps ensure the patient can maintain a patent airway, which is essential in ARF management.

Answer 158

A) The patient demonstrates the ability to cough independently. Rationale: The ability to cough independently is a direct indicator that the patient can effectively clear secretions, which is a key goal for those with ARF to prevent further respiratory complications.

Answer 159

B) Encouraging early ambulation and teaching deep breathing exercises. Rationale: For patients at high risk of ARF, preventive strategies like early ambulation and teaching deep breathing exercises can help reduce the risk of complications such as atelectasis and pneumonia, which are common causes of ARF.

Answer 160

B) Performing frequent position changes and encouraging incentive spirometry. Rationale: Frequent position changes and the use of incentive spirometry can help prevent atelectasis and pneumonia, which are important strategies for preventing ARF in patients with neuromuscular or respiratory issues.

Answer 161

D) Mild crackles heard in the lower lung fields on auscultation. Rationale: Mild crackles in the lower lung fields may indicate early signs of atelectasis or fluid accumulation, which are risk factors for ARF. Addressing this early through interventions like deep breathing exercises or incentive spirometry can help prevent further deterioration.

Answer 162

C) “I should avoid coughing because it might irritate my lungs.” Rationale: Coughing is a vital protective mechanism for clearing secretions and preventing complications such as pneumonia. The patient should be taught the importance of coughing to prevent respiratory failure, not avoid it.

Answer 163

C) Teaching the patient to use the incentive spirometer every hour. Rationale: Incentive spirometry is an essential tool in preventing atelectasis and improving lung expansion, especially in patients with COPD, who are at high risk for ARF due to airway obstruction and impaired gas exchange.

Answer 164

A) Encouraging hourly incentive spirometry use and frequent position changes. Rationale: Encouraging the use of the incentive spirometer and frequent position changes helps prevent atelectasis and pneumonia, which are critical preventive measures for patients at risk for ARF.

Answer 165

D) Encouraging early and frequent ambulation to promote lung expansion. Rationale: Early and frequent ambulation is essential in preventing respiratory complications, including ARF, especially for patients who are immobile and at high risk for atelectasis and pneumonia.

Answer 166

A) Administering supplemental oxygen to increase the oxygen supply. Rationale: For patients with V/Q mismatch, supplemental oxygen is essential to improve oxygenation and ventilation. Oxygen therapy helps correct the mismatch between ventilation and perfusion, improving overall oxygen delivery.

Answer 167

C) Increase in PaO2 and decrease in PaCO2. Rationale: An increase in PaO2 and a decrease in PaCO2 indicate improved oxygenation and ventilation, which is essential in treating diffusion impairment in ARF. This shows better gas exchange and clinical improvement.

Answer 168

D) Assessing for improvement in respiratory rate and ABG values. Rationale: Monitoring the patient’s respiratory rate and trends in ABG values is essential in assessing the effectiveness of interventions aimed at improving oxygenation and ventilation in ARF. These parameters directly reflect the patient’s respiratory status and response to treatment.

Answer 169

D) Providing mechanical ventilation with positive end-expiratory pressure (PEEP) to improve oxygenation. Rationale: For patients with ARF caused by shunting, PEEP is often used in mechanical ventilation to improve oxygenation by preventing alveolar collapse and improving oxygen exchange, which addresses the mismatch in ventilation and perfusion.

Answer 170

B) Assess the patient for signs of worsening hypoxemia and notify the healthcare provider. Rationale: If the patient is not responding to supplemental oxygen and is showing signs of worsening respiratory distress, it is crucial to assess for worsening hypoxemia and notify the healthcare provider for further intervention. This may require additional therapies or adjustments to the treatment plan.

Answer 171

C) Increase oxygen therapy and prepare for potential intubation. Rationale: For a patient with a diffusion impairment and significantly low PaO2 and high PaCO2, increasing oxygen therapy and preparing for intubation is crucial to support ventilation and oxygenation. This intervention addresses the impaired gas exchange caused by diffusion issues in ARF.

Answer 172

D) Implementing positive pressure ventilation to improve CO2 removal. Rationale: Positive pressure ventilation can help improve CO2 removal, which is crucial for correcting acid-base imbalances, particularly in cases of respiratory acidosis. It supports ventilation by helping to expel CO2, improving the patient’s overall acid-base status.

Answer 173

C) Administering a bronchodilator and encouraging the patient to cough and deep breathe. Rationale: Administering a bronchodilator can help open the airways, making it easier for the patient to cough and clear secretions. This is an important step in improving oxygenation and mobilizing secretions effectively.

Answer 174

A) The patient is able to speak in full sentences without pausing to breathe. Rationale: The ability to speak in full sentences without pausing to breathe indicates improved oxygenation and ventilation, demonstrating the effectiveness of the respiratory therapy in maintaining adequate oxygenation.

Answer 175

B) Correct hypoxemia while using the lowest effective FiO2. Rationale: The goal of oxygen therapy is to correct hypoxemia while administering the lowest FiO2 needed to maintain adequate oxygenation, thereby reducing the risk of oxygen toxicity.

Answer 176

B) Assess for signs of worsening hypoxemia and explore alternative oxygen delivery options. Rationale: Restlessness and agitation can be signs of worsening hypoxemia. The nurse should assess the patient’s respiratory status and consider alternative delivery devices that ensure adequate oxygenation while minimizing anxiety.

Answer 177

A) Oxygen toxicity. Rationale: High concentrations of oxygen for extended periods can lead to oxygen toxicity, causing alveolar damage, inflammation, and cellular death.

Answer 178

A) The patient may develop respiratory depression due to a blunted CO2 response. Rationale: In patients with chronic hypercapnia, high oxygen levels can blunt the respiratory drive, leading to respiratory depression.

Answer 179

A) Oxygen toxicity B) Absorption atelectasis E) Fibrotic changes in the alveoli Rationale: High FiO2 levels can lead to oxygen toxicity, alveolar collapse due to nitrogen displacement (absorption atelectasis), and long-term fibrotic changes in lung tissue.

Answer 180

C) The patient’s PaO2 trends toward 60 mm Hg or higher. Rationale: A PaO2 of 60 mm Hg or higher indicates improved oxygenation.

Answer 181

D) Change to a Venturi mask delivering 24%-28% FiO2. Rationale: A Venturi mask provides precise oxygen concentrations, making it ideal for COPD patients to prevent excessive oxygen delivery and CO2 retention.

Answer 182

B) The patient is not responding to oxygen therapy and may need mechanical ventilation. Rationale: If a patient remains hypoxemic despite high-flow oxygen, mechanical ventilation may be required.

Answer 183

B) Decreased breath sounds and new-onset hypoxemia. Rationale: Absorption atelectasis occurs when nitrogen is displaced by oxygen, leading to alveolar collapse, decreased breath sounds, and worsening hypoxemia.

Answer 184

C) Increase the oxygen flow rate to ensure adequate reservoir filling. Rationale: The reservoir bag should not fully collapse; increasing the oxygen flow rate ensures proper oxygen delivery.

Answer 185

B) Surfactant inactivation and alveolar damage Rationale: Prolonged exposure to high oxygen concentrations can lead to decreased surfactant production, alveolar injury, and fibrosis.

Answer 186

A) Check ABG results for worsening hypoxemia. Rationale: Agitation and confusion can indicate worsening hypoxemia, requiring immediate assessment.

Answer 187

B) Oxygen toxicity Rationale: Oxygen toxicity can cause neurological symptoms such as muscle twitching and dizziness due to excess oxygen radicals.

Answer 188

A) Assess the patient’s respiratory status and ABG values. Rationale: A full assessment is essential to determine appropriate oxygen therapy.

Answer 189

A) A patient with ARF requiring precise oxygen delivery. Rationale: Venturi masks provide precise oxygen concentrations, making them ideal for patients requiring controlled oxygenation.

Answer 190

B) Encouraging adequate hydration and providing humidified oxygen Rationale: Hydration and humidified oxygen therapy help thin and mobilize secretions, making it easier for the patient to clear them.

Answer 191

A) Placing the patient in a high-Fowler’s position and performing chest physiotherapy Rationale: Positioning and chest physiotherapy (e.g., postural drainage, percussion, vibration) promote secretion mobilization and clearance.

Answer 192

C) Perform endotracheal suctioning to remove retained secretions Rationale: Coarse breath sounds and decreased oxygen saturation suggest secretion retention, which can impair gas exchange. Suctioning is necessary to remove secretions and improve oxygenation.

Answer 193

A) Encourage deep breathing and use of an incentive spirometer Rationale: Incentive spirometry and deep breathing exercises promote lung expansion and secretion mobilization, helping to prevent complications such as atelectasis.

Answer 194

D) Elevate the head of the bed to at least 30 degrees Rationale: Elevating the head of the bed promotes lung expansion, decreases dyspnea, and enhances oxygenation, which is essential in managing ARF.

Answer 195

A) Right side-lying position (good lung down) Rationale: Placing the patient in a lateral position with the “good lung down” maximizes ventilation-perfusion (V/Q) matching and improves oxygenation.

Answer 196

B) Reposition the patient regularly from side to side Rationale: Regular repositioning helps mobilize secretions, optimize air movement, and improve overall oxygenation, especially in patients with bilateral lung involvement.

Answer 197

B) Side-lying position Rationale: A side-lying position reduces the risk of aspiration by preventing secretions from pooling in the airway.

Answer 198

A) Have the patient lean slightly forward while sitting Rationale: A forward-leaning position, such as the tripod position, promotes better diaphragm movement and reduces work of breathing.

Answer 199

A) Positioning the patient in a prone position Rationale: Prone positioning can improve oxygenation by promoting alveolar recruitment and better ventilation-perfusion matching, particularly in patients with ARF related to ARDS.

Answer 200

A) Left side-lying Rationale: The “good lung down” position (left side-lying for right-sided pneumonia) promotes secretion drainage from the affected lung and enhances ventilation in the healthier lung.

Answer 201

D) Improved oxygenation due to enhanced ventilation-perfusion matching Rationale: Placing the “good lung down” improves ventilation and perfusion, which enhances oxygenation in patients with unilateral lung disease.

Answer 202

A. “I should take a deep breath, hold it for a few seconds, and then forcefully exhale while saying ‘huff.’” Rationale: Huff coughing is a technique that keeps the glottis open while expelling air, reducing airway collapse and making secretion clearance more effective. The patient should take a deep breath, hold it briefly, and then exhale forcefully while saying “huff.” This method is particularly beneficial for patients with conditions like COPD.

Answer 203

D. Instruct the patient to perform huff coughing. Rationale: Huff coughing is an effective technique for patients with COPD and retained secretions. It generates sufficient airflow without causing excessive fatigue, preventing airway collapse while clearing mucus.

Answer 204

A. Perform suctioning to remove secretions. Rationale: In a mechanically ventilated patient with worsening oxygenation and audible secretions, immediate suctioning is required to remove mucus and improve gas exchange. Augmented coughing is ineffective for an intubated patient, and increasing FiO₂ does not address the underlying issue.

Answer 205

C. “I should lie flat in bed while performing this technique.” Rationale: The staged cough is most effective when the patient is in a sitting position, which promotes better lung expansion and secretion clearance. Lying flat may impair diaphragmatic movement and increase the risk of aspiration.

Answer 206

B. Applying firm pressure at the anterolateral base of the lungs during exhalation. Rationale: Augmented coughing (quad coughing) involves applying firm pressure to the anterolateral base of the patient’s lungs during exhalation to help generate sufficient force for secretion clearance. This technique is useful for patients with weak respiratory muscles.

Answer 207

B. Administer bronchodilators and mucolytics. Rationale: Mucolytics help break down thick secretions, making them easier to clear, while bronchodilators open airways, facilitating secretion movement. Increased fluid intake may help long-term, but immediate pharmacologic intervention is often required in critical patients.

Answer 208

C. Performing huff coughing to clear the airways. Rationale: Huff coughing prevents airway collapse by keeping the glottis open, making it the preferred method for COPD patients to clear secretions effectively.

Answer 209

D. Teach the patient augmented coughing techniques. Rationale: Augmented coughing helps patients with weak respiratory muscles generate enough force to expel secretions. Increasing fluids may help long-term, but immediate intervention is needed. An albuterol nebulizer would be used for bronchospasms rather than secretion clearance.

Answer 210

B. Perform percussion and vibration over the affected lung segments. Rationale: Percussion and vibration help mobilize secretions by loosening mucus from the airways. These techniques allow secretions to move toward larger airways, where they can be removed by coughing or suctioning.

Answer 211

C. Hold CPT and notify the healthcare provider. Rationale: Chest physiotherapy is contraindicated in patients with increased ICP due to the risk of worsening cerebral edema and neurological compromise. The nurse should avoid CPT and inform the provider.

Answer 212

C. Trendelenburg position with the patient lying prone. Rationale: The Trendelenburg position with the patient prone allows for optimal drainage of the posterior lower lobes by using gravity to move secretions toward larger airways. This position should be avoided in patients with increased ICP or hemodynamic instability.

Answer 213

D. Hold CPT and inform the provider of the contraindication. Rationale: Chest physiotherapy is contraindicated in patients with unstable orthopedic injuries, including fractured sternum, as percussion and vibration could worsen the injury. The nurse should hold the therapy and inform the provider.

Answer 214

C. Nasopharyngeal suctioning with a soft-tip catheter Rationale: Nasopharyngeal suctioning is the preferred method for removing secretions in a non-intubated, conscious patient who cannot clear their airway. This technique is effective for reaching secretions at the back of the throat while minimizing discomfort.

Answer 215

A. Stop suctioning immediately and provide 100% oxygen. Rationale: A drop in oxygen saturation and agitation indicate hypoxia, a possible complication of suctioning. The priority is to stop suctioning and deliver 100% oxygen to prevent further desaturation and respiratory distress.

Answer 216

B. Apply suction for no longer than 10–15 seconds per pass. Rationale: Prolonged suctioning (>15 seconds) can cause hypoxia, bradycardia, and airway trauma. Suction should be applied intermittently while withdrawing the catheter to minimize mucosal damage.

Answer 217

A. Encourage the patient to cough before initiating suctioning. Rationale: Encouraging the patient to cough before suctioning helps mobilize secretions naturally, reducing the need for deep suctioning. This minimizes airway trauma and discomfort.

Answer 218

B. SpO₂ decreasing from 96% to 89% after therapy Rationale: A sudden drop in oxygen saturation following aerosol therapy suggests bronchospasm or secretion mobilization obstructing airflow. The nurse must intervene immediately by stopping the treatment, assessing for respiratory distress, and possibly administering a bronchodilator or oxygen support.

Answer 219

C. Assess for bronchospasm and oxygen desaturation during treatment. Rationale: Aerosol therapy can trigger bronchospasm and coughing, potentially leading to a drop in oxygen levels. Continuous assessment ensures prompt intervention if the patient experiences complications.

Answer 220

A. “Humidification helps thin secretions and promotes their removal.” C. “Bronchospasm is a potential complication of aerosolized humidification therapy.” D. “Oxygen administered via aerosol mask can assist with secretion clearance.” Rationale: * A is correct: Humidification thins secretions and promotes their removal. * C is correct: Bronchospasm is a possible complication of aerosol therapy. * D is correct: Oxygen via aerosol mask helps in secretion clearance. * B is incorrect: Acetylcysteine is often mixed with a bronchodilator to prevent bronchospasm. * E is incorrect: Mild coughing is expected as secretions loosen; therapy is only stopped if severe distress occurs.

Answer 221

C. Assess breath sounds and oxygen saturation while monitoring for bronchospasm. Rationale: Persistent coughing and shortness of breath could indicate bronchospasm. The nurse should first assess for wheezing, hypoxia, and worsening respiratory distress before deciding on further interventions.

Answer 222

B. Have emergency airway equipment available before starting therapy. Rationale: Acetylcysteine can trigger bronchospasm. Emergency airway equipment should be available in case of severe respiratory distress.

Answer 223

A. Increased ease of breathing B. Decreased respiratory rate from 24 to 18 breaths/min D. Improved ability to clear secretions by coughing Rationale: * A is correct: Easier breathing suggests improved secretion clearance. * B is correct: A decreased respiratory rate indicates less respiratory distress. * D is correct: Effective coughing means secretions are mobilizing. * C is incorrect: Secretions should be thinner and easier to expectorate. * E is incorrect: Increased accessory muscle use suggests worsening distress, not improvement.

Answer 224

A. “Humidification helps thin secretions and promotes their removal.” C. “Bronchospasm is a potential complication of aerosolized humidification therapy.” D. “Oxygen administered via aerosol mask can assist with secretion clearance.” Rationale: * A is correct: Humidification thins secretions and promotes their removal. * C is correct: Bronchospasm is a possible complication of aerosol therapy. * D is correct: Oxygen via aerosol mask helps in secretion clearance. * B is incorrect: Acetylcysteine is often mixed with a bronchodilator to prevent bronchospasm. * E is incorrect: Mild coughing is expected as secretions loosen; therapy is only stopped if severe distress occurs.

Answer 225

C. Reduce the IV fluid rate and monitor respiratory status closely. Rationale: New-onset crackles, dyspnea, and elevated CVP suggest early fluid overload. The nurse should slow the IV fluid rate while monitoring respiratory status to prevent pulmonary edema.

Answer 226

C. “If I feel short of breath or notice swelling, I should drink extra fluids to keep my lungs clear.” Rationale: Shortness of breath and swelling may indicate fluid overload, not dehydration. Increasing fluid intake in this situation could worsen pulmonary edema.

Answer 227

D. Notify the provider and anticipate a fluid restriction. Rationale: Oliguria (low urine output), worsening respiratory distress, and crackles suggest fluid retention due to AKI. Increasing fluids could worsen pulmonary edema, so the nurse should anticipate fluid restriction and notify the provider.

Answer 228

A. New-onset bilateral crackles B. Jugular vein distention D. Sudden weight gain of 2 kg (4.4 lbs) in 24 hours E. Increased work of breathing Rationale: * A is correct: Crackles suggest pulmonary congestion due to excess fluid. * B is correct: Jugular vein distention indicates increased central venous pressure. * D is correct: Rapid weight gain signals fluid retention. * E is correct: Increased work of breathing suggests worsening respiratory distress. * C is incorrect: A urine output of 50 mL/hr is normal and does not indicate fluid overload.

Answer 229

B. Assess for proper mask fit and ensure the patient is tolerating the therapy. Rationale: Agitation and hypoxemia may indicate mask leaks or intolerance to BiPAP. The first step is to assess mask fit and ensure adequate ventilation before considering escalation to intubation.

Answer 230

B. Decreased work of breathing and improved mental status Rationale: BiPAP should reduce respiratory muscle fatigue, improve oxygenation, and decrease work of breathing. Improved mental status indicates better oxygen delivery to the brain.

Answer 231

D. Prepare for endotracheal intubation. Rationale: Drowsiness, decreased respiratory rate, and increasing PaCO₂ suggest CO₂ retention and respiratory failure. CPAP does not provide ventilation support, so intubation is necessary to correct hypercapnia.

Answer 232

B. A patient with severe facial trauma C. A patient with ARF and copious respiratory secretions E. A patient with altered mental status and inability to protect the airway Rationale: * B is correct: Facial trauma prevents an adequate mask seal for effective ventilation. * C is correct: Excessive secretions increase aspiration risk and compromise airway clearance. * E is correct: An altered mental status impairs the ability to maintain a patent airway. * A and D are incorrect because BiPAP/CPAP can effectively manage COPD exacerbations and pulmonary edema.

Answer 233

B. “BiPAP is preferred for ARF because it provides different pressures for inhalation and exhalation.” Rationale: BiPAP delivers higher pressure during inhalation and lower pressure during exhalation, reducing work of breathing. CPAP provides a constant pressure throughout the respiratory cycle.

Answer 234

Air is being forced into the esophagus and stomach. Rationale: Excessive BiPAP pressure can lead to gastric insufflation, causing bloating and discomfort. The nurse should assess the pressure settings and consider adjusting them.

Answer 235

D. All of the above Rationale: BiPAP can cause hypoventilation if settings are inadequate, barotrauma from excessive pressure, and hypotension due to reduced venous return.

Answer 236

C. Decreased respiratory rate and improved SpO₂ Rationale: CPAP should improve oxygenation and reduce respiratory distress by decreasing fluid accumulation in the lungs.

Answer 237

C. “I feel really sleepy and can’t stay awake.” Rationale: Excessive drowsiness may indicate CO₂ retention and worsening respiratory failure. The nurse should assess PaCO₂ levels and ventilatory support.

Answer 238

A. Apply a skin barrier to prevent facial pressure ulcers. B. Monitor for gastric insufflation and abdominal bloating. D. Assess for signs of CO₂ retention and altered mental status. Rationale: * A is correct: Skin breakdown is a common complication. * B is correct: Gastric insufflation can cause discomfort and nausea. * D is correct: CO₂ retention may occur if settings are inadequate. * C is incorrect: Increasing inspiratory pressure without assessment may worsen discomfort. * E is incorrect: Patients do not need to be NPO unless they have aspiration risk

Answer 239

A. Corticosteroids Rationale: Corticosteroids are used to reduce airway inflammation and bronchospasm in patients with respiratory conditions like ARF. They help improve airflow by decreasing inflammation in the airways.

Answer 240

B. Administer bronchodilators first, followed by antibiotics. Rationale: Bronchodilators should be administered before antibiotics because they help open the airways, allowing the antibiotics to reach the lungs more effectively. Administering bronchodilators first reduces airway resistance and optimizes the patient’s ability to inhale the medication.

Answer 241

C. Benzodiazepines Rationale: Benzodiazepines are used to reduce anxiety and restlessness in patients with ARF. They help to calm the patient and improve comfort while the primary respiratory issues are being addressed.

Answer 242

D. Tachycardia and hypertension Rationale: Short-acting bronchodilators (e.g., albuterol) can cause tachycardia and hypertension as side effects. These are due to the sympathetic nervous system stimulation caused by the medication.

Answer 243

C. Discontinue the albuterol and notify the physician. Rationale: The nurse should discontinue the albuterol if significant side effects like tachycardia and hypertension occur, and notify the physician immediately. These side effects may indicate excessive stimulation of the sympathetic nervous system, which could lead to complications such as dysrhythmias or cardiac ischemia.

Answer 244

B. 4 to 5 days for optimum therapeutic effects Rationale: Inhaled corticosteroids typically take 4 to 5 days to achieve optimum therapeutic effects and may not provide immediate relief of symptoms or quick relief of dyspnea or increased work of breathing (WOB).

Answer 245

C. B. “It will take a few hours for this medication to work.” Rationale: IV methylprednisolone may take several hours to show therapeutic effects, especially in terms of reducing inflammation and bronchospasm. It is not an immediate-acting medication for acute bronchospasm.

Answer 246

D. Assess the patient’s respiratory status and hold further doses of albuterol if necessary. Rationale: Tachycardia and hypertension are potential side effects of albuterol. The nurse should assess the patient’s respiratory status and vital signs and withhold further doses if needed, notifying the physician about the side effects and patient condition.

Answer 247

A. To reduce airway inflammation and relieve bronchospasm Rationale: Corticosteroids, such as methylprednisolone, are combined with bronchodilators to reduce airway inflammation and relieve bronchospasm, improving airflow and oxygenation. They work together to address both inflammation and airway constriction.

Answer 248

B. Discontinue the albuterol and notify the healthcare provider. Rationale: Tachycardia is a potential side effect of albuterol and can indicate excessive sympathetic nervous system stimulation. Discontinuing the medication and notifying the healthcare provider is the appropriate action, as the patient may need a different treatment plan to manage bronchospasm.

Answer 249

C. Hypokalemia and hypotension Rationale: Furosemide (a diuretic) can cause hypokalemia (low potassium) and hypotension (low blood pressure). These are common side effects of diuretics, which promote fluid loss. The nurse should closely monitor the patient’s electrolyte levels and blood pressure.

Answer 250

A. Decreased respiratory rate and hypotension Rationale: Morphine can cause respiratory depression (decreased respiratory rate) and hypotension (low blood pressure). It is used in pulmonary congestion for its ability to reduce anxiety, decrease venous return, and improve oxygenation, but the nurse must monitor for these side effects.

Answer 251

A. Blood pressure and heart rate Rationale: Nitroglycerin works by reducing pulmonary congestion and preload, but it can cause significant decreases in blood pressure and changes in heart rate. The nurse should closely monitor the patient’s vital signs, especially for hypotension or bradycardia.

Answer 252

C. Risk for dysrhythmias and hypotension Rationale: Both IV diuretics (e.g., furosemide) and morphine can lead to hypotension and dysrhythmias. Diuretics can cause fluid and electrolyte imbalances, and morphine can reduce blood pressure and cause respiratory depression. Monitoring the patient’s vital signs and ECG is essential for preventing complications.

Answer 253

A. Inflammation and fluid-filled alveoli prevent gas exchange Rationale: Pulmonary infections (e.g., pneumonia) can cause inflammation and fluid-filled alveoli, which prevents effective gas exchange. This results in a worsening of ARF as the alveoli cannot properly exchange oxygen and carbon dioxide.

Answer 254

A. Administering IV antibiotics and obtaining sputum cultures Rationale: The most effective treatment for lung infections involves IV antibiotics to treat the infection and obtaining sputum cultures to identify the causative organism and guide antimicrobial therapy. This will help manage infection and prevent further complications of ARF.

Answer 255

B. Assess the location and extent of lung involvement Rationale: A chest x-ray is an essential diagnostic tool used to assess the location and extent of the infection, including fluid-filled or collapsed alveoli. It provides visual evidence of the infection’s severity and helps guide further treatment decisions.

Answer 256

D. Sputum production should decrease, and fever should subside Rationale: After starting IV antibiotics, the patient should show improvement in infection symptoms. Sputum production should decrease, and fever should subside as the infection is controlled. Monitoring these changes is essential in determining the effectiveness of the treatment.

Answer 257

B. Sputum culture Rationale: Sputum cultures are essential in identifying the specific organisms causing the lung infection and determining their sensitivity to antimicrobial drugs. This helps guide the most appropriate treatment with antibiotics.

Answer 258

A. Increased oxygen consumption and carbon dioxide production Rationale: Anxiety, pain, and restlessness can increase oxygen consumption and carbon dioxide production due to an elevated metabolic rate, which increases the work of breathing (WOB). This can worsen hypoxemia and dyspnea in patients with ARF.

Answer 259

C. Assess for treatable causes such as hypoxemia or pain Rationale: The priority is to assess for treatable causes such as hypoxemia, pain, or ventilator dyssynchrony. Restlessness and mental status changes are often the first signs of these conditions, so addressing the underlying cause is essential before administering sedatives or analgesics.

Answer 260

C. Providing emotional support and reassurance Rationale: Providing emotional support and reassurance to the patient and caregiver is critical in reducing anxiety and restlessness. This approach can help alleviate the stress caused by the patient’s condition, improving overall comfort.

Answer 261

B. Adjust the ventilator settings to improve synchronization Rationale: If ventilator dyssynchrony is suspected, it is important to first adjust the ventilator settings to improve synchronization. This helps reduce restlessness and improve overall ventilatory support. Managing hypoxemia and adjusting the ventilator settings are more effective than solely increasing sedatives.

Answer 262

D. Respiratory depression and hypotension Rationale: Benzodiazepines and opioids like lorazepam and morphine can cause respiratory depression and hypotension as side effects. Monitoring the patient for these complications is essential to ensure safe medication use and prevent further respiratory compromise.

Answer 263

D. Assess for treatable causes of the restlessness, such as hypoxemia or pain Rationale: Restlessness and mental status changes are often early signs of hypoxemia or other treatable conditions. The nurse should assess and address the underlying causes rather than immediately increasing the dose of lorazepam, which could worsen the patient’s condition.

Answer 264

A. Provide reassurance and maintain frequent communication with the patient Rationale: Reassurance and maintaining frequent communication with the patient can help reduce anxiety and prevent unplanned extubation. Providing emotional support and explaining the ventilator settings and goals can increase patient cooperation and comfort.

Answer 265

A. Oxygen saturation levels and respiratory rate Rationale: Lorazepam and morphine can cause respiratory depression, so it is crucial to closely monitor oxygen saturation and respiratory rate to detect any potential respiratory compromise and ensure patient safety.

Answer 266

B. The lowest possible dose to reduce the risk of sedation Rationale: It is important to administer lorazepam at the lowest possible dose to reduce the risk of over-sedation and respiratory depression. The goal is to manage anxiety without compromising the patient’s respiratory status.

Answer 267

B. Preventing protein and energy depletion Rationale: In a hypermetabolic state, such as critical illness, it is crucial to maintain protein and energy stores to prevent depletion, which could lead to loss of muscle mass (including respiratory muscles) and delay recovery.

Answer 268

B. EN supports protein and energy stores to prevent muscle mass loss Rationale: Enteral nutrition (EN) is recommended within 24 to 48 hours of admission to maintain protein and energy stores to prevent muscle mass loss, which is especially important in critical illness, as muscle loss can delay recovery.

Answer 269

B. Increase the patient’s energy stores and support muscle mass Rationale: The primary goal of enteral nutrition (EN) is to provide adequate energy and protein to support muscle mass and energy stores in the face of a hypermetabolic state, which is critical in preventing further muscle wasting and delayed recovery.

Answer 270

D. Assess the patient’s response to nutrition therapy and adjust as necessary Rationale: The nurse’s role in enteral nutrition (EN) therapy includes assessing the patient’s response to the therapy and making necessary adjustments. The dietitian typically determines the optimal calorie and fluid requirements and feeding method, but ongoing monitoring and adjustments by the nurse are essential to ensure adequate nutritional support.

Answer 271

C. The patient’s oxygenation is stable, with a PaO2 within the normal range Rationale: A successful outcome in the management of ARF includes adequate oxygenation, demonstrated by a normal PaO2. Maintaining oxygenation is one of the key expected outcomes in ARF management.

Answer 272

A. The patient no longer requires supplemental oxygen Rationale: Returning to baseline respiratory function means the patient has sufficient respiratory function to maintain oxygenation without supplemental oxygen. This reflects improved respiratory health and stability.

Answer 273

D. The patient requires less oxygen and demonstrates stable hemodynamics Rationale: An improvement in ARF is indicated when the patient requires less oxygen and demonstrates stable hemodynamics, meaning their cardiovascular and respiratory functions are stabilizing and returning to baseline levels.

Answer 274

B. The decreased physiologic reserve and poor nutritional status of the patient Rationale: Decreased physiologic reserve and poor nutritional status make older adults more susceptible to worsening ARF due to the inability to compensate for respiratory and metabolic stresses.

Answer 275

C. Decreased response to changes in PaO2 and PaCO2 levels Rationale: Older adults have a decreased response to changes in PaO2 and PaCO2 levels, which contributes to respiratory insufficiency and increases the risk of ARF.

Answer 276

B. Tobacco use accelerates age-related changes in the respiratory system Rationale: Tobacco use accelerates age-related respiratory changes, such as decreased lung elasticity and muscle strength, which increases the risk of respiratory failure.

Answer 277

C. Decreased chest wall compliance and respiratory muscle strength Rationale: Aging causes decreased chest wall compliance and reduced respiratory muscle strength, which reduces ventilatory efficiency and contributes to the increased risk of ARF.

Answer 278

D. Decreased ventilatory capacity, leading to an increased risk of ARF Rationale: Aging results in decreased ventilatory capacity, which increases the risk of ARF due to changes such as alveolar dilation, decreased lung elasticity, and diminished respiratory muscle strength.

Answer 279

C. Increased PaCO2 levels and delayed stimulation of the respiratory system Rationale: Aging causes the PaCO2 levels to rise higher before the respiratory system is stimulated to change the rate and depth of breathing, resulting in a delayed response to respiratory insufficiency.

Answer 280

C. Decreased respiratory muscle strength and lung elasticity Rationale: Aging leads to decreased respiratory muscle strength, reduced lung elasticity, and decreased chest wall compliance, all of which contribute to the increased risk of ARF in older adults.

Answer 281

a. Cyanosis b. Tachypnea d. Paradoxical breathing

Answer 282

d. base the selection on the patient’s condition and amount of FIO2 needed.

Answer 283

c. Arterial blood gases Rationale: Arterial blood gas (ABG) analysis is the most specific information because ventilatory failure causes problems with CO2 retention, and ABGs give information about the PaCO 2 and pH. Chest x-ray, oxygen saturation, and central venous pressure monitoring may also be done to help in assessing oxygenation or determining the cause of the patient‘s ventilatory failure.

Answer 284

b. Increase the prescribed O 2 flowrate. Rationale: Increasing O2 flowrate will usually improve O2 saturation in patients with ventilation-perfusion mismatch, as occurs with pulmonary embolism. Because the problem is with perfusion, actions that improve ventilation, such as deep breathing and coughing, sitting upright, and suctioning, are not likely to improve oxygenation.

Answer 285

b. Endotracheal intubation and positive pressure ventilation Rationale: The patient‘s lethargy, low respiratory rate, and SpO2 indicate the need for mechanical ventilation with ventilator-controlled respiratory rate. Giving high-flow O2 will not be helpful because the patient‘s respiratory rate is so low. Insertion of a mini-tracheostomy will promote removal of secretions, but it will not improve the patient‘s respiratory rate or oxygenation. CPAP requires that the patient initiate an adequate respiratory rate to allow adequate gas exchange.

Answer 286

b. Assist the patient with staged coughing. Rationale: The patient‘s assessment indicates that assisted coughing is needed to help remove secretions, which will improve oxygenation. A 4-hour rest period at this time may allow the O2 saturation to drop further. Humidification will not be helpful unless the secretions can be mobilized. Positioning on the left side may cause a further decrease in oxygen saturation because perfusion will be directed more toward the more poorly ventilated lung.

Answer 287

a. On the left side 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.

Answer 288

a. The patient appears somnolent. Rationale: Increasing somnolence will decrease the patient‘s respiratory rate and effort and further increase the PaCO 2 . 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.

Answer 289

a. Elevate head of bed to 30 to 45 degrees. Rationale: Elevation of the head decreases the risk for aspiration. Positive end-expiratory pressure is frequently needed to improve oxygenation in patients receiving mechanical ventilation. Suctioning should be done only when the patient assessment indicates that it is necessary. Enteral feedings should provide adequate calories for the patient‘s high energy needs.

Answer 290

b. Offer the patient fluids at frequent intervals. Rationale: Thick, viscous secretions are hard to expel. Adequate fluid intake (2 to 3 L/day) keeps secretions thin and easier to remove, so the best action will be to encourage the patient to improve oral fluid intake. Patients should be instructed to use the incentive spirometer on a regular basis (e.g., every hour) to facilitate the clearance of the secretions. The other actions may be helpful in improving the patient‘s gas exchange, but they do not address the thick secretions that are causing the poor airway clearance.

Answer 291

c. The patient‘s respiratory rate is 10 breaths/min. Rationale: A drop in respiratory rate in a patient with respiratory distress suggests the onset of fatigue and a high risk for respiratory arrest. Therefore, immediate action such as positive-pressure ventilation is needed. Patients who are experiencing respiratory distress frequently sit in the tripod position because it decreases the work of breathing. Crackles in the lung bases may be the baseline for a patient with COPD. An O2 saturation of 91% is common in patients with COPD and will provide adequate gas exchange and tissue oxygenation.

Answer 292

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 flowrate.

Answer 293

c. Use pulse oximetry to check the oxygen saturation. Rationale: Agitation may be an early indicator of hypoxemia. The other actions may also be appropriate, depending on the findings about O2 saturation.

Answer 294

b. Provide a “sedation holiday” daily. c. Give prescribed pantoprazole (Protonix). d. Elevate the head of the bed to at least 30 degrees. e. Provide oral care daily with chlorhexidine (0.12%) solution. Rationale: 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.

CH 32: Acute Respiratory Failure (ARF) Flashcards

(318 cards)