1
ARF/ARDS
10. Which statement by the nurse when explaining the purpose of positive
R
end-expiratory pressure (PEEP) to the family members of a patient with ARDS is
E
accurate?
H
a. "PEEP will push more air into the lungs during inhalation."
b. "PEEP prevents the lung air sacs from collapsing during exhalation."
IG
c. "PEEP will prevent lung damage while the patient is on the ventilator."
d. "PEEP allows the breathing machine to deliver 100% oxygen to the lungs." - ANS
H
ANS: B
G
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
IN
ARDS), push more air into the lungs, or change the fraction of inspired oxygen (FIO2)
delivered to the patient.
Y
DIF: Cognitive Level: Understand (comprehension) REF: 1669
L
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
F
11. A patient with acute respiratory distress syndrome (ARDS) is placed in the prone
position. When prone positioning is used, 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.
, 2
c. Sputum and blood cultures show no growth after 48 hours.
d. The skin on the patient's back is intact and without redness. - ANS ANS: A
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
R
whether prone positioning has been effective.
E
DIF: Cognitive Level: Apply (application) REF: 1670
H
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
G
12. The nurse documents the vital signs for a patient admitted 2 days ago with
I
gram-negative sepsis: temperature 101.2° F, blood pressure 90/56 mm Hg, pulse 92,
H
respirations 34. Which action should the nurse take next?
G
a. Give the scheduled IV antibiotic.
b. Give the PRN acetaminophen (Tylenol).
N
c. Obtain oxygen saturation using pulse oximetry.
I
d. Notify the health care provider of the patient's vital signs. - ANS ANS: C
Y
The patient's increased respiratory rate in combination with the admission diagnosis of
L
gram-negative sepsis indicates that acute respiratory distress syndrome (ARDS) may
F
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.
DIF: Cognitive Level: Apply (application) REF: 1665 | 1667
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
, 3
14. A patient admitted with acute respiratory failure has a nursing diagnosis of
ineffective airway clearance related to thick, secretions. Which action is a priority for the
nurse to include in the plan of care?
R
a. Encourage use of the incentive spirometer.
E
b. Offer the patient fluids at frequent intervals.
H
c. Teach the patient the importance of ambulation.
d. Titrate oxygen level to keep O2 saturation >93%. - ANS ANS: B
G
Because the reason for the poor airway clearance is the thick secretions, the best action
I
will be to encourage the patient to improve oral fluid intake. Patients should be
H
instructed to use the incentive spirometer on a regular basis (e.g., every hour) in order
G
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
N
are causing the poor airway clearance.
I
DIF: Cognitive Level: Apply (application) REF: 1662
Y
OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning
L
MSC: NCLEX: Physiological Integrity
F
15. A patient with acute respiratory distress syndrome (ARDS) who is intubated and
receiving mechanical ventilation develops a right pneumothorax. Which action will the
nurse anticipate taking next?
a. Increase the tidal volume and respiratory rate.
b. Increase the fraction of inspired oxygen (FIO2).
ARF/ARDS
10. Which statement by the nurse when explaining the purpose of positive
R
end-expiratory pressure (PEEP) to the family members of a patient with ARDS is
E
accurate?
H
a. "PEEP will push more air into the lungs during inhalation."
b. "PEEP prevents the lung air sacs from collapsing during exhalation."
IG
c. "PEEP will prevent lung damage while the patient is on the ventilator."
d. "PEEP allows the breathing machine to deliver 100% oxygen to the lungs." - ANS
H
ANS: B
G
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
IN
ARDS), push more air into the lungs, or change the fraction of inspired oxygen (FIO2)
delivered to the patient.
Y
DIF: Cognitive Level: Understand (comprehension) REF: 1669
L
TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity
F
11. A patient with acute respiratory distress syndrome (ARDS) is placed in the prone
position. When prone positioning is used, 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.
, 2
c. Sputum and blood cultures show no growth after 48 hours.
d. The skin on the patient's back is intact and without redness. - ANS ANS: A
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
R
whether prone positioning has been effective.
E
DIF: Cognitive Level: Apply (application) REF: 1670
H
TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity
G
12. The nurse documents the vital signs for a patient admitted 2 days ago with
I
gram-negative sepsis: temperature 101.2° F, blood pressure 90/56 mm Hg, pulse 92,
H
respirations 34. Which action should the nurse take next?
G
a. Give the scheduled IV antibiotic.
b. Give the PRN acetaminophen (Tylenol).
N
c. Obtain oxygen saturation using pulse oximetry.
I
d. Notify the health care provider of the patient's vital signs. - ANS ANS: C
Y
The patient's increased respiratory rate in combination with the admission diagnosis of
L
gram-negative sepsis indicates that acute respiratory distress syndrome (ARDS) may
F
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.
DIF: Cognitive Level: Apply (application) REF: 1665 | 1667
OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation
, 3
14. A patient admitted with acute respiratory failure has a nursing diagnosis of
ineffective airway clearance related to thick, secretions. Which action is a priority for the
nurse to include in the plan of care?
R
a. Encourage use of the incentive spirometer.
E
b. Offer the patient fluids at frequent intervals.
H
c. Teach the patient the importance of ambulation.
d. Titrate oxygen level to keep O2 saturation >93%. - ANS ANS: B
G
Because the reason for the poor airway clearance is the thick secretions, the best action
I
will be to encourage the patient to improve oral fluid intake. Patients should be
H
instructed to use the incentive spirometer on a regular basis (e.g., every hour) in order
G
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
N
are causing the poor airway clearance.
I
DIF: Cognitive Level: Apply (application) REF: 1662
Y
OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning
L
MSC: NCLEX: Physiological Integrity
F
15. A patient with acute respiratory distress syndrome (ARDS) who is intubated and
receiving mechanical ventilation develops a right pneumothorax. Which action will the
nurse anticipate taking next?
a. Increase the tidal volume and respiratory rate.
b. Increase the fraction of inspired oxygen (FIO2).
