Chapter 67

Question 1

1. Which diagnostic test will provide the nurse with the most specific information to evaluate the effectiveness of interventions for a patient with ventilatory failure?
   a. Chest x-ray
   b. O2 saturation
   c. Arterial blood gas analysis
   d. Central venous pressure monitoring

Answer 1

ANS: C : Arterial blood gas analysis

Arterial blood gas (ABG) analysis is most useful in this setting because ventilatory failure causes problems with CO2 retention, and ABGs provide information about the PaCO2 and pH. The other tests may also be done to help in assessing oxygenation or determining the cause of the patient’s ventilatory failure.

Question 2

2. While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient’s oxygen saturation (SpO2) from 94% to 88%. Which action should the nurse take?
   a. Suction the patient’s oropharynx.
   b. Increase the prescribed O2 flow rate.
   c. Instruct the patient to cough and deep breathe.
   d. Help the patient to sit in a more upright position.

Answer 2

ANS: B : increase the prescribed O2 flow rate.

Increasing O2 flow rate 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

Question 3

3. A patient with respiratory failure has a respiratory rate of 6 breaths/min and an oxygen saturation (SpO2) of 88%. The patient is increasingly lethargic. Which intervention will the nurse anticipate?
   a. Administration of 100% O2 by non-rebreather mask
   b. Endotracheal intubation and positive pressure ventilation
   c. Insertion of a mini-tracheostomy with frequent suctioning
   d. Initiation of continuous positive pressure ventilation (CPAP)

Answer 3

ANS: B : Endotracheal intubation and positive pressure ventilation

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 facilitate 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

Question 4

4. The oxygen saturation (SpO2) for a patient with left lower lobe pneumonia is 90%. The patient has wheezes, a weak cough effort, and complains of fatigue. Which action should the nurse take next?
   a. Position the patient on the left side.
   b. Assist the patient with staged coughing.
   c. Place a humidifier in the patient’s room.
   d. Schedule a 4-hour rest period for the patient.

Answer 4

ANS: B : Assist the patient with staged coughing.

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.

Question 5

5. A nurse is caring for an obese patient with right lower lobe pneumonia. Which position will be best to improve gas exchange?
   a. On the left side
   b. On the right side
   c. In the tripod position
   d. In the high-Fowler’s position

Answer 5

ANS: A : On the left side

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.

Question 6

6. When admitting a patient with possible respiratory failure and a high PaCO2, which assessment information should be immediately reported to the health care provider?
   a. The patient is very somnolent.
   b. The patient complains of weakness.
   c. The patient’s blood pressure is 164/98.
   d. The patient’s oxygen saturation is 90%.

Answer 6

ANS: A : The patient is very somnolent.

Increasing somnolence will decrease the patient’s respiratory rate and further increase the PaCO2 and respiratory failure. Rapid action is needed to prevent respiratory arrest. An SpO2 of 90%, weakness, and elevated blood pressure all require ongoing monitoring but are not indicators of possible impending respiratory arrest.

Question 7

7. A patient with acute respiratory distress syndrome (ARDS) and acute kidney injury has the following drugs ordered. Which drug should the nurse discuss with the health care provider before giving?
   a. gentamicin 60 mg IV
   b. pantoprazole (Protonix) 40 mg IV
   c. sucralfate (Carafate) 1 g per nasogastric tube
   d. methylprednisolone (Solu-Medrol) 60 mg IV

Answer 7

ANS: A : gentamicin 60 mg IV

Gentamicin, which is one of the aminoglycoside antibiotics, is potentially nephrotoxic, and the nurse should clarify the drug and dosage with the health care provider before administration. The other drugs are appropriate for the patient with ARDS.

Question 8

8. A patient develops increasing dyspnea and hypoxemia 2 days after heart surgery. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by heart failure, the nurse will plan to assist with
   a. obtaining a ventilation-perfusion scan.
   b. drawing blood for arterial blood gases.
   c. positioning the patient for a chest x-ray.
   d. insertion of a pulmonary artery catheter.

Answer 8

ANS: D : insertion of a pulmonary artery catheter.
Pulmonary artery wedge pressures are normal in the patient with ARDS because the fluid in the alveoli is caused by increased permeability of the alveolar-capillary membrane rather than by the backup of fluid from the lungs (as occurs in cardiogenic pulmonary edema). The other tests will not help in differentiating cardiogenic from noncardiogenic pulmonary edema.

Question 9

9. A nurse is caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP). Which assessment finding by the nurse indicates that the PEEP may need to be reduced?
   a. The patient’s PaO2 is 50 mm Hg and the SaO2 is 88%.
   b. The patient has subcutaneous emphysema on the upper thorax.
   c. The patient has bronchial breath sounds in both the lung fields.

d. The patient has a first-degree atrioventricular heart block with a rate of 58
beats/min.

Answer 9

ANS: B :The patient has subcutaneous emphysema on the upper thorax.

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

Question 10

10. Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the patient’s caregiver is accurate?
    a. “PEEP will push more air into the lungs during inhalation.”
    b. “PEEP prevents the lung air sacs from collapsing during exhalation.”
    c. “PEEP will prevent lung damage while the patient is on the ventilator.”
    d. “PEEP allows the breathing machine to deliver 100% O2 to the lungs.”

Answer 10

ANS: B : “PEEP prevents the lung air sacs from collapsing during exhalation.”
By preventing alveolar collapse during expiration, PEEP improves gas exchange and oxygenation. PEEP will not prevent lung damage (e.g., fibrotic changes that occur with ARDS), push more air into the lungs, or change the fraction of inspired oxygen (FIO2) delivered to the patient.

Question 11

11. When prone positioning is used for a patient with acute respiratory distress syndrome (ARDS), which information obtained by the nurse indicates that the positioning is effective?
    a. The patient’s PaO2 is 89 mm Hg, and the SaO2 is 91%.
    b. Endotracheal suctioning results in clear mucous return.
    c. Sputum and blood cultures show no growth after 48 hours.
    d. The skin on the patient’s back is intact and without redness.

Answer 11

ANS: A : The patient’s PaO2 is 89 mm Hg, and the SaO2 is 91%.

The purpose of prone positioning is to improve the patient’s oxygenation as indicated by the PaO2 and SaO2. The other information will be collected but does not indicate whether prone positioning has been effective.

Question 12

12. The nurse assesses vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature of 101.2° F, blood pressure of 90/56 mm Hg, pulse of 92 beats/min, and respirations of 34 breaths/min. Which action should the nurse take next?
    a. Give the scheduled IV antibiotic.
    b. Give the PRN acetaminophen (Tylenol).
    c. Obtain oxygen saturation using pulse oximetry.
    d. Notify the health care provider of the patient’s vital signs.

Answer 12

ANS: C : Obtain oxygen saturation using pulse oximetry.

The patient’s increased respiratory rate in combination with the admission diagnosis of gram-negative sepsis indicates that acute respiratory distress syndrome (ARDS) may be developing. The nurse should check for hypoxemia, a hallmark of ARDS. The health care provider should be notified after further assessment of the patient. Giving the scheduled antibiotic and the PRN acetaminophen will also be done, but they are not the highest priority for a patient who may be developing ARDS.

Question 13

13. A nurse is caring for a patient who is orally intubated and receiving mechanical ventilation. To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care?
    a. Elevate head of bed to 30 to 45 degrees.
    b. Give enteral feedings at no more than 10 mL/hr.
    c. Suction the endotracheal tube every 2 to 4 hours.
    d. Limit the use of positive end-expiratory pressure.

Answer 13

ANS: A : Elevate head of bed to 30 to 45 degrees.

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.

Question 14

14. A patient admitted with acute respiratory failure has ineffective airway clearance related to thick secretions. Which nursing intervention would specifically address this patient problem?
    a. Encourage use of the incentive spirometer.
    b. Offer the patient fluids at frequent intervals.
    c. Teach the patient the importance of ambulation.
    d. Titrate oxygen level to keep O2 saturation above 93%.

Answer 14

ANS: B : Offer the patient fluids at frequent intervals.

Because the reason for the poor airway clearance is the thick secretions, the best action will be to encourage the patient to improve oral fluid intake. Patients should be instructed to use the incentive spirometer on a regular basis (e.g., every hour) to facilitate the clearance of the secretions. The other actions may also be helpful in improving the patient’s gas exchange, but they do not address the thick secretions that are causing the poor airway clearance.

Question 15

15. A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation develops a right pneumothorax. Which collaborative action will the nurse anticipate next?
    a. Increase the tidal volume and respiratory rate.
    b. Decrease the fraction of inspired oxygen (FIO2).
    c. Perform endotracheal suctioning more frequently.
    d. Lower the positive end-expiratory pressure (PEEP).

Answer 15

ANS: D : Lower the positive end-expiratory pressure (PEEP).

Because barotrauma is associated with high airway pressures, the level of PEEP should be decreased. The other actions will not decrease the risk for another pneumothorax.

Question 16

16. After receiving change-of-shift report on a medical unit, which patient should the nurse assess first?
    a. A patient with cystic fibrosis who has thick, green-colored sputum
    b. A patient with pneumonia who has crackles bilaterally in the lung bases
    c. A patient with emphysema who has an oxygen saturation of 90% to 92%
    d. A patient with septicemia who has intercostal and suprasternal retractions

Answer 16

ANS: D : A patient with septicemia who has intercostal and suprasternal retractions

This patient’s history of septicemia and labored breathing suggest the onset of ARDS, which will require rapid interventions such as administration of O2 and use of positive-pressure ventilation. The other patients should also be assessed, but their assessment data are typical of their disease processes and do not suggest deterioration in their status.

Question 17

17. A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department complaining of shortness of breath and dyspnea on minimal exertion. Which assessment finding by the nurse is most important to report to the health care provider?
    a. The patient has bibasilar lung crackles.
    b. The patient is sitting in the tripod position.
    c. The patient’s pulse oximetry indicates a 91% O2 saturation.
    d. The patient’s respirations have dropped to 10 breaths/minute.

Answer 17

ANS: D : he patient’s respirations have dropped to 10 breaths/minute.

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.

Question 18

18. When assessing a patient with chronic obstructive pulmonary disease (COPD), the nurse finds a new onset of agitation and confusion. Which action should the nurse take first?
    a. Observe for facial symmetry.
    b. Notify the health care provider.
    c. Attempt to calm and reorient the patient.
    d. Assess oxygenation using pulse oximetry.

Answer 18

ANS: D : Assess oxygenation using pulse oximetry.

Because agitation and confusion are frequently the initial indicators of hypoxemia, the nurse’s initial action should be to assess O2 saturation. The other actions are also appropriate, but assessment of oxygenation takes priority over other assessments and notification of the health care provider.

Question 19

19. The nurse is caring for a patient who arrived in the emergency department with acute respiratory distress. Which assessment finding by the nurse requires the most rapid action?
    a. The patient’s PaO2 is 45 mm Hg.
    b. The patient’s PaCO2 is 33 mm Hg.
    c. The patient’s respirations are shallow.
    d. The patient’s respiratory rate is 32 breaths/min.

Answer 19

ANS: A : The patient’s PaO2 is 45 mm Hg.

The PaO2 indicates severe hypoxemia and respiratory failure. Rapid action is needed to prevent further deterioration of the patient. Although the shallow breathing, rapid respiratory rate, and low PaCO2 also need to be addressed, the most urgent problem is the patient’s poor oxygenation.

Question 20

20. The nurse is caring for an older patient who was hospitalized 2 days earlier with community-acquired pneumonia. Which assessment information is most important to communicate to the health care provider?
    a. Persistent cough of blood-tinged sputum.
    b. Scattered crackles in the posterior lung bases.
    c. Oxygen saturation 90% on 100% O2 by nonrebreather mask.
    d. Temperature 101.5° F (38.6° C) after 2 days of IV antibiotics.

Answer 20

ANS: C : Oxygen saturation 90% on 100% O2 by nonrebreather mask.

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 require continued monitoring. The continued temperature elevation indicates a possible need to change antibiotics, but this is not as urgent a concern as the progression toward hypoxemia despite an increase in O2 flow rate.

Question 21

21. Which nursing interventions included in the care of a mechanically ventilated patient with acute respiratory failure can the registered nurse (RN) delegate to an experienced licensed practical/vocational nurse (LPN/LVN) working in the intensive care unit?
    a. Assess breath sounds every hour.
    b. Monitor central venous pressures.
    c. Place patient in the prone position.
    d. Insert an indwelling urinary catheter.

Answer 21

ANS: D : insert an indwelling urinary catheter.

Insertion of indwelling urinary catheters is included in LPN/LVN education and scope of practice and can be safely delegated to an LPN/LVN who is experienced in caring for critically ill patients. Placing a patient who is on a ventilator in the prone position requires multiple staff, and should be supervised by an RN. Assessment of breath sounds and obtaining central venous pressures require advanced assessment skills and should be done by the RN caring for a critically ill patient.

Question 22

22. A nurse is caring for a patient with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation using synchronized intermittent mandatory ventilation (SIMV). The settings include fraction of inspired oxygen (FIO2) of 80%, tidal volume of 450, rate of 16/minute, and positive end-expiratory pressure (PEEP) of 5 cm. Which assessment finding is most important for the nurse to report to the health care provider?
    a. O2 saturation of 99%
    b. Heart rate 106 beats/minute
    c. Crackles audible at lung bases
    d. Respiratory rate 22 breaths/minute

Answer 22

ANS: A : O2 saturation of 99%

The FIO2 of 80% increases the risk for O2 toxicity. Because the patient’s O2 saturation is 99%, a decrease in FIO2 is indicated to avoid toxicity. The other patient data would be typical for a patient with ARDS and would not be the most important data to report to the health care provider.

Question 23

23. Which information about a patient who is receiving cisatracurium (Nimbex) to prevent asynchronous breathing with the positive pressure ventilator requires action by the nurse?
    a. No sedative has been ordered for the patient.
    b. The patient does not respond to verbal stimulation.
    c. There is no cough or gag reflex when the patient is suctioned.
    d. The patient’s oxygen saturation remains between 90% to 93%.

Answer 23

ANS: A : No sedative has been ordered for the patient.

Because neuromuscular blockade is extremely anxiety provoking, it is essential that patients who are receiving neuromuscular blockade receive concurrent sedation and analgesia. Absence of response to stimuli is expected in patients receiving neuromuscular blockade. The O2 saturation is adequate.

Question 24

24. The nurse is caring for a patient who is intubated and receiving positive pressure ventilation to treat acute respiratory distress syndrome (ARDS). Which finding is most important to report to the health care provider?
    a. Red-brown drainage from nasogastric tube
    b. Blood urea nitrogen (BUN) level 32 mg/dL
    c. Scattered coarse crackles heard throughout lungs
    d. Arterial blood gases: pH of 7.31, PaCO2 of 50, and PaO2 of 68

Answer 24

ANS: A: Red-brown drainage from nasogastric tube

The nasogastric drainage indicates possible gastrointestinal bleeding or stress ulcer and should be reported. The pH and PaCO2 are slightly abnormal, but current guidelines advocating for permissive hypercapnia indicate that these would not indicate an immediate need for a change in therapy. The BUN is slightly elevated but does not indicate an immediate need for action. Adventitious breath sounds are commonly heard in patients with ARDS.

Question 25

25. During change-of-shift report on a medical unit, the nurse learns that a patient with aspiration pneumonia who was admitted with respiratory distress has become increasingly agitated. Which action should the nurse take first?
    a. Give the prescribed PRN sedative drug.
    b. Offer reassurance and reorient the patient.
    c. Use pulse oximetry to check the oxygen saturation.
    d. Notify the health care provider about the patient’s status.

Answer 25

ANS: C : Use pulse oximetry to check the oxygen saturation.

Agitation may be an early indicator of hypoxemia. The other actions may also be appropriate, depending on the findings about O2 saturation.

Question 26

26. The nurse reviews the electronic health record for a patient scheduled for a total hip replacement. Which assessment data shown in the accompanying figure increase the patient’s risk for respiratory complications after surgery?
    a. Older age and anemia
    b. Albumin level and weight loss
    c. Recent arthroscopic procedure
    d. Confusion and disorientation to time

Answer 26

ANS: B : Albumin level and weight loss

The patient’s recent weight loss and low protein stores indicate possible muscle weakness, which make it more difficult for an older patient to recover from the effects of general anesthesia and immobility associated with the hip surgery. The other information will also be noted by the nurse but does not place the patient at higher risk for respiratory failure.

Question 27

1. Which actions should the nurse start to reduce the risk for ventilator-associated pneumonia (VAP) (select all that apply)?
   a. Obtain arterial blood gases daily.
   b. Provide a “sedation holiday” daily.
   c. Give prescribed pantoprazole (Protonix).
   d. Elevate the head of the bed to at least 30°.
   e. Provide oral care with chlorhexidine (0.12%) solution daily

Answer 27

ANS: B, C, D, E

All of these interventions are part of the ventilator bundle that is recommended to prevent VAP. Arterial blood gases may be done daily but are not always necessary and do not help prevent VAP.