Chapter 67: Acute Respiratory Failure and Acute Respiratory Distress Syndrome Lewis: Medical-Surgical Nursing, 10th Edition

Chapter 67: Acute Respiratory Failure and Acute Respiratory Distress Syndrome Lewis: Medical-Surgical Nursing, 10th Edition MULTIPLE CHOICE 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 ANS: C 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. DIF: Cognitive Level: Apply (application) REF: 1614 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 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. ANS: B 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.