NUR 265 Exam 2 UPDATED Questions
and CORRECT Answers
Acute respiratory failure: - CORRECT ANSWER classified by blood gas abnormalities;
partial pressure of arterial oxygen (Pao2) less than 60mm Hg, arterial saturation (Sao2) less than
90% or partial pressure of arterial carbon dioxide (Paco2) more than 50mm Hg occurring with
acidemia (pH<7.30)
• Ventilation failure - CORRECT ANSWER is a problem in oxygen intake (ventilation)
and blood delivery (perfusion); perfusion is normal but ventilation is inadequate; chest pressure
does not change enough to permit air movement into and out of the lungs, too little oxygen
reaches the alveoli and carbon dioxide is retained leading to hypoxemia
o Extrapulmonary causes of ventilation failure - CORRECT ANSWER Neuromuscular
disorders (Myasthenia gravis, Guillian-Barre, poliomyelitis)
Spinal cord injuries affecting nerves to intercoastal muscles
CNS dysfunction (stroke, increased ICP, Meningitis)
Chemical depression (opioids, sedatives, anesthetics)
Massive obesity
Kyphoscoliosis
Sleep apnea
External obstruction/construction
o Intrapulmonary causes of ventilation failure - CORRECT ANSWER Airway disease
(COPD, asthma)
Ventilation-perfusion mismatch:
• PE
• Pneumothorax
• ARDS
• Amyloidosis
• Pulmonary edema
,• Interstitial fibrosis
• Oxygenation failure: - CORRECT ANSWER chest pressure changes are normal and air
moves in and out w/o difficulty but does not oxygenate the blood sufficiently, perfusion is
decreased
oxygenation failure causes - CORRECT ANSWER Low atmospheric oxygen
concentration (high altitudes, closed spaces, smoke inhalation, carbon monoxide poisoning)
Pneumonia
CHF with pulmonary edema
PE
ARDS
Interstitial pneumonitis-fibrosis
Abnormal Hgb
Hypovolemic shock
Hypoventilation
Complications of nitroprusside therapy (thiocyanate toxicity, methemoglobinemia)
oxygenation failure assessment - CORRECT ANSWER o Assess for dyspnea (difficulty
breathing; hallmark sign of respiratory failure)
o Assess for change in respiratory rate or pattern
o Changes in lung sounds
o Manifestations of hypoxemia (pallor, cyanosis, increased HR, restlessness, confusion)
o Manifestations of hypercarbia (high arterial blood levels of carbon dioxide)
o May have decreased Spo2
o ABG most accurate assessment of oxygenation
oxygenation failure TX - CORRECT ANSWER o Oxygen therapy is appropriate for any
patient with acute hypoxemia
o Use to keep Pao2 level above 60 mm Hg while treating cause of resp failure
,o Mechanical ventilation may be needed
o Position patient upright in comfortable position that facilitates ease breathing
o Use relaxation, diversion, and guided imagery to decrease anxiety
o Energy saving measures (limit self-care activities, no unnecessary procedures)
o MDI may be prescribed to widen bronchioles and decrease inflammation to promote gas
exchange
o Encourage deep breathing
Acute Respiratory Distress Syndrome: - CORRECT ANSWER exchange of oxygen for
carbon dioxide in the lungs is inadequate for oxygen consumption and carbon dioxide production
within the body cells
• Unexpected and catastrophic pulmonary complication occurring in a person with no previous
pulmonary problems; patients are critically ill and managed in ICU
• Major site of injury is alveolar capillary membrane
• Interstitial edema causes compression and obliteration of the terminal airways and leads to
reduced lung volume/compliance
• ABG levels reveal respiratory acidosis and hypoxemia that do not respond to increased % of
oxygen
characteristics of ARDS - CORRECT ANSWER o Hypoxemia that persists when 100%
O2 given
o Decreased pulmonary compliance
o Dyspnea
o Non-cardiac associated bilateral pulmonary edema
No abnormal lung sounds are present on auscultation b/c edema of ARDS occurs 1st in the
interstitial spaces and not the airways
o Dense pulmonary infiltrates on x-ray
causes of ARDS - CORRECT ANSWER o Exacerbation of COPD
o PN
o TB
, o Contusion/neurological injuries
o Sepsis
o Burns
o Aspiration
o Inhaled toxins
o Emboli
o Drug OD
o Fluid overload
o Shock
o trauma
o DIC (disseminated intravascular coagulation)
s/s and assessment of ARDS - CORRECT ANSWER o Decreased breath sounds
o Tachypnea, Dyspnea, hyperpnea, crackles or rales
o Intercostal retractions
o Cyanosis, pallor
o Hypoxemia: SpO2 <50mm Hg with FiO2 >60%
o Diffuse pulmonary infiltrates on x-ray ("white out")
o Verbalized anxiety/restlessness
• Plans/nursing interventions for ARDS - CORRECT ANSWER o Identify and treat the
cause of the ARDS
o Positioning for maximum lung expansion, fowlers
o Restrict fluid intake as perscribed
o Monitor for s/s of hypoxemia and oxygen toxicity
***Suction only when secretions are present
o Monitor breath sounds for pneumothorax
o Provide emotional support to decrease anxiety and allow ventilator to "work" the lungs
and CORRECT Answers
Acute respiratory failure: - CORRECT ANSWER classified by blood gas abnormalities;
partial pressure of arterial oxygen (Pao2) less than 60mm Hg, arterial saturation (Sao2) less than
90% or partial pressure of arterial carbon dioxide (Paco2) more than 50mm Hg occurring with
acidemia (pH<7.30)
• Ventilation failure - CORRECT ANSWER is a problem in oxygen intake (ventilation)
and blood delivery (perfusion); perfusion is normal but ventilation is inadequate; chest pressure
does not change enough to permit air movement into and out of the lungs, too little oxygen
reaches the alveoli and carbon dioxide is retained leading to hypoxemia
o Extrapulmonary causes of ventilation failure - CORRECT ANSWER Neuromuscular
disorders (Myasthenia gravis, Guillian-Barre, poliomyelitis)
Spinal cord injuries affecting nerves to intercoastal muscles
CNS dysfunction (stroke, increased ICP, Meningitis)
Chemical depression (opioids, sedatives, anesthetics)
Massive obesity
Kyphoscoliosis
Sleep apnea
External obstruction/construction
o Intrapulmonary causes of ventilation failure - CORRECT ANSWER Airway disease
(COPD, asthma)
Ventilation-perfusion mismatch:
• PE
• Pneumothorax
• ARDS
• Amyloidosis
• Pulmonary edema
,• Interstitial fibrosis
• Oxygenation failure: - CORRECT ANSWER chest pressure changes are normal and air
moves in and out w/o difficulty but does not oxygenate the blood sufficiently, perfusion is
decreased
oxygenation failure causes - CORRECT ANSWER Low atmospheric oxygen
concentration (high altitudes, closed spaces, smoke inhalation, carbon monoxide poisoning)
Pneumonia
CHF with pulmonary edema
PE
ARDS
Interstitial pneumonitis-fibrosis
Abnormal Hgb
Hypovolemic shock
Hypoventilation
Complications of nitroprusside therapy (thiocyanate toxicity, methemoglobinemia)
oxygenation failure assessment - CORRECT ANSWER o Assess for dyspnea (difficulty
breathing; hallmark sign of respiratory failure)
o Assess for change in respiratory rate or pattern
o Changes in lung sounds
o Manifestations of hypoxemia (pallor, cyanosis, increased HR, restlessness, confusion)
o Manifestations of hypercarbia (high arterial blood levels of carbon dioxide)
o May have decreased Spo2
o ABG most accurate assessment of oxygenation
oxygenation failure TX - CORRECT ANSWER o Oxygen therapy is appropriate for any
patient with acute hypoxemia
o Use to keep Pao2 level above 60 mm Hg while treating cause of resp failure
,o Mechanical ventilation may be needed
o Position patient upright in comfortable position that facilitates ease breathing
o Use relaxation, diversion, and guided imagery to decrease anxiety
o Energy saving measures (limit self-care activities, no unnecessary procedures)
o MDI may be prescribed to widen bronchioles and decrease inflammation to promote gas
exchange
o Encourage deep breathing
Acute Respiratory Distress Syndrome: - CORRECT ANSWER exchange of oxygen for
carbon dioxide in the lungs is inadequate for oxygen consumption and carbon dioxide production
within the body cells
• Unexpected and catastrophic pulmonary complication occurring in a person with no previous
pulmonary problems; patients are critically ill and managed in ICU
• Major site of injury is alveolar capillary membrane
• Interstitial edema causes compression and obliteration of the terminal airways and leads to
reduced lung volume/compliance
• ABG levels reveal respiratory acidosis and hypoxemia that do not respond to increased % of
oxygen
characteristics of ARDS - CORRECT ANSWER o Hypoxemia that persists when 100%
O2 given
o Decreased pulmonary compliance
o Dyspnea
o Non-cardiac associated bilateral pulmonary edema
No abnormal lung sounds are present on auscultation b/c edema of ARDS occurs 1st in the
interstitial spaces and not the airways
o Dense pulmonary infiltrates on x-ray
causes of ARDS - CORRECT ANSWER o Exacerbation of COPD
o PN
o TB
, o Contusion/neurological injuries
o Sepsis
o Burns
o Aspiration
o Inhaled toxins
o Emboli
o Drug OD
o Fluid overload
o Shock
o trauma
o DIC (disseminated intravascular coagulation)
s/s and assessment of ARDS - CORRECT ANSWER o Decreased breath sounds
o Tachypnea, Dyspnea, hyperpnea, crackles or rales
o Intercostal retractions
o Cyanosis, pallor
o Hypoxemia: SpO2 <50mm Hg with FiO2 >60%
o Diffuse pulmonary infiltrates on x-ray ("white out")
o Verbalized anxiety/restlessness
• Plans/nursing interventions for ARDS - CORRECT ANSWER o Identify and treat the
cause of the ARDS
o Positioning for maximum lung expansion, fowlers
o Restrict fluid intake as perscribed
o Monitor for s/s of hypoxemia and oxygen toxicity
***Suction only when secretions are present
o Monitor breath sounds for pneumothorax
o Provide emotional support to decrease anxiety and allow ventilator to "work" the lungs
