Acute Respiratory Distress Syndrome (ARDS) Management, Exams of Nursing

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A patient presents to the emergency department in acute respiratory failure secondary to community-acquired pneumonia. The patient has a history of chronic obstructive pulmonary disease. The nurse anticipates which treatment to facilitate ventilation? a. Emergency tracheostomy and mechanical ventilation b. Mechanical ventilation via an endotracheal tube c. Noninvasive positive-pressure ventilation (NPPV) d. Oxygen at 100% via bag-valve-mask device Correct Answer c. Noninvasive positive-pressure ventilation (NPPV) Which of the following acid-base disturbances commonly occurs with the hyperventilation and impaired gas exchange seen in severe exacerbation of asthma? a. Metabolic acidosis b. Metabolic alkalosis c. Respiratory acidosis d. Respiratory alkalosis Correct Answer c. Respiratory acidosis An acute exacerbation of asthma is treated with which of the following? a. Corticosteroids and theophylline by mouth

b. Inhaled bronchodilators and intravenous corticosteroids c. Prone positioning or continuous lateral rotation d. Sedation and inhaled bronchodilators Correct Answer b. Inhaled bronchodilators and intravenous corticosteroids The nurse is discharging a patient home following treatment for community-acquired pneumonia. As part of the discharge teaching, the nurse instructs, a. "If you get the pneumococcal vaccine, you'll never get pneumonia again." b. "It is important for you to get an annual influenza shot to reduce your risk of pneumonia." c. "Stay away from cold, drafty places because that increases your risk of pneumonia when you get home." d. "Since you have been treated for pneumonia, you now have immunity from getting it in the future." Correct Answer b. "It is important for you to get an annual influenza shot to reduce your risk of pneumonia." The nurse is discharging a patient with asthma. As part of the discharge instruction, the nurse instructs the patient to prevent exacerbation by: a. obtaining an appointment for follow-up pulmonary function studies 1 week after discharge. b. limiting activity until the patient is able to climb two flights of stairs. c. taking all asthma medications as prescribed. d. taking medications on a "prn" basis according to symptoms. Correct Answer c. taking all asthma medications as prescribed.

The nurse is caring for a postoperative patient with chronic obstructive pulmonary disease (COPD). Which assessment would be a cue to the patient developing postoperative pneumonia? a. Bradycardia b. Change in sputum characteristics c. Hypoventilation and respiratory acidosis d. Pursed-lip breathing Correct Answer b. Change in sputum characteristics The nurse is caring for a patient with a diagnosis of pulmonary embolism. The nurse understands that the most common cause of a pulmonary embolus is a. amniotic fluid embolus. b. deep vein thrombosis from lower extremities. c. fat embolus from a long bone fracture. d. vegetation that dislodges from an infected central venous catheter. Correct Answer b. deep vein thrombosis from lower extremities. The nurse is concerned that a patient is at increased risk of developing a pulmonary embolus and develops a plan of care for prevention to include which of the following? a. Antiseptic oral care b. Bed rest with head of bed elevated c. Coughing and deep breathing d. Mobility Correct Answer d. Mobility Which of the following statements is true regarding venous thromboembolism (VTE) and pulmonary embolus (PE)?

a. PE should be suspected in any patient who has unexplained cardiorespiratory complaints and risk factors for VTE. b. Bradycardia and hyperventilation are classic symptoms of PE. c. Dyspnea, chest pain, and hemoptysis occur in nearly all patients with PE. d. Most critically ill patients are at low risk for VTE and PE and do not require prophylaxis. Correct Answer a. PE should be suspected in any patient who has unexplained cardiorespiratory complaints and risk factors for VTE. A patient at high risk for pulmonary embolism is receiving enoxaparin. The nurse explains to the patient: a. "I'm going to contact the pharmacist to see if you can take this medication by mouth." b. "This injection is being given to prevent blood clots from forming." c. "This medication will dissolve any blood clots you might get." d. "You should not be receiving this medication. I will contact the provider to get it stopped." Correct Answer b. "This injection is being given to prevent blood clots from forming." A definitive diagnosis of pulmonary embolism can be made by a. arterial blood gas (ABG) analysis. b. chest x-ray examination. c. pulmonary angiogram.

d. ventilation-perfusion scanning. Correct Answer c. pulmonary angiogram. A strategy for preventing pulmonary embolism in patients at risk who cannot take anticoagulants is a. administration of two aspirin tablets every 4 hours. b. infusion of thrombolytics. c. insertion of a vena cava filter. d. subcutaneous heparin administration every 12 hours. Correct Answer c. insertion of a vena cava filter. Which of the following treatments may be used to dissolve a thrombus that is lodged in the pulmonary artery? a. Aspirin b. Embolectomy c. Heparin d. Thrombolytics Correct Answer d. Thrombolytics The nurse is assessing a patient. Which assessment would cue the nurse to the potential of acute respiratory distress syndrome (ARDS)? a. Increased oxygen saturation via pulse oximetry b. Increased peak inspiratory pressure on the ventilator c. Normal chest radiograph with enlarged cardiac structures d. PaO2/FiO2 ratio >300 Correct Answer b. Increased peak inspiratory pressure on the ventilator The nurse calculates the PaO2/FiO2 ratio for the following values: PaO2 is 78 mm Hg; FiO2 is 0.6 (60%). a. 46.8; meets criteria for ARDS

b. 130; meets criteria for ARDS c. 468; normal lung function d. Not enough data to compute the ratio Correct Answer b. 130; meets criteria for ARDS The nurse is assessing a patient with acute respiratory distress syndrome. An expected assessment is a. cardiac output of 10 L/min and low systemic vascular resistance. b. PAOP of 10 mm Hg and PaO2 of 55. c. PAOP of 20 mm Hg and cardiac output of 3 L/min. d. PAOP of 5 mm Hg and high systemic vascular resistance. Correct Answer b. PAOP of 10 mm Hg and PaO2 of 55. The nurse is caring for a patient who is being turned prone as part of treatment for acute respiratory distress syndrome. The nurse understands that the priority nursing concern for this patient is which of the following? a. Management and protection of the airway b. Prevention of gastric aspiration c. Prevention of skin breakdown and nerve damage d. Psychological support to patient and family Correct Answer a. Management and protection of the airway During rounds, the provider alerts the team that proning is being considered for a patient with acute respiratory distress syndrome. The nurse understands that proning is a. an optional treatment to improve ventilation. b. less of a risk for skin breakdown because the patient is face down.

c. possible with minimal help from coworkers. d. used to provide continuous lateral rotational turning. Correct Answer a. an optional treatment to improve ventilation. The etiology of noncardiogenic pulmonary edema in acute respiratory distress syndrome (ARDS) is related to damage to the a. alveolar-capillary membrane. b. left ventricle. c. mainstem bronchus. d. trachea. Correct Answer a. alveolar-capillary membrane. Identify diagnostic criteria for ARDS. (Select all that apply.) a. Bilateral infiltrates on chest x-ray study b. Decreased cardiac output c. PaO2/ FiO2 ratio of less than 200 d. Pulmonary artery occlusion pressure (PAOP) of more than 18 mm Hg e. PAOP less than 18 mm Hg Correct Answer a. Bilateral infiltrates on chest x-ray study c. PaO2/ FiO2 ratio of less than 200 Which of the following statements is true regarding oral care for the prevention of ventilator-associated pneumonia (VAP)? (Select all that apply.) a. Tooth brushing is performed every 2 hours for the greatest effect. b. Implementing a comprehensive oral care program is an intervention for preventing VAP.

c. Oral care protocols should include oral suctioning and brushing teeth. d. Protocols that include chlorhexidine gluconate have been effective in preventing VAP. e. Using oral swabs or toothettes are just as effective as brushing the teeth. Correct Answer b. Implementing a comprehensive oral care program is an intervention for preventing VAP. c. Oral care protocols should include oral suctioning and brushing teeth. d. Protocols that include chlorhexidine gluconate have been effective in preventing VAP. Which of the following are physiological effects of positive end-expiratory pressure (PEEP) used in the treatment of ARDS? (Select all that apply.) a. Increases functional residual capacity b. Prevents collapse of unstable alveoli c. Improves arterial oxygenation d. Opens collapsed alveoli e. Improves carbon dioxide retention Correct Answer a. Increases functional residual capacity b. Prevents collapse of unstable alveoli c. Improves arterial oxygenation d. Opens collapsed alveoli Which of the following are components of the Institute for Healthcare Improvement's (IHI's) ventilator bundle? (Select all that apply.) a. Interrupt sedation each day to assess readiness to extubate.

b. Maintain head of bed at least 30 degrees of elevation. c. Provide deep vein thrombosis prophylaxis. d. Provide prophylaxis for peptic ulcer disease. e. Swab the mouth with foam swabs every 2 hours. Correct Answer a. Interrupt sedation each day to assess readiness to extubate. b. Maintain head of bed at least 30 degrees of elevation. c. Provide deep vein thrombosis prophylaxis. d. Provide prophylaxis for peptic ulcer disease. Select the strategies for preventing deep vein thrombosis (DVT) and pulmonary embolus (PE). (Select all that apply.) a. Graduated compression stockings b. Heparin or low-molecular weight heparin for patients at risk c. Sequential compression devices d. Strict bed rest e. Leg massage Correct Answer a. Graduated compression stockings b. Heparin or low-molecular weight heparin for patients at risk c. Sequential compression devices The nurse is caring for a mechanically ventilated patient. The nurse understands that strategies to prevent ventilator-associated pneumonia include which of the following? (Select all that apply.) a. Drain condensate from the ventilator tubing away from the patient. b. Elevate the head of the bed 30 to 45 degrees.

c. Instill normal saline as part of the suctioning procedure. d. Perform regular oral care with chlorhexidine. e. Awaken the patient daily to determine the need for continued ventilation. Correct Answer a. Drain condensate from the ventilator tubing away from the patient. b. Elevate the head of the bed 30 to 45 degrees d. Perform regular oral care with chlorhexidine. You have just received change of shift report. Which patient should you assess first? a. 62 year-old man who is scheduled for a cardiac cath, and is ready to be transported now b. 58 year-old woman with COPD with an O2 saturation of 92% on 2 liters of O2, who is scheduled to be discharged home on O c. 36 year-old man admitted with an exacerbation of asthma with RR 36 at rest, and whose wheezing has diminished d. 72 year-old woman with history of asthma with HR 90 and is due for her beta-blocker Correct Answer C RR 36 and diminished wheezing indicative of respiratory distress and needs prompt attention You are about to handover patient care to your on-coming nurse colleague. Which patient requires the most immediate attention? 1.) 62 year-old man with COPD who has just completed his scheduled bronchodilator 2.) 68 year-old woman with type 2 diabetes who had CVA 2 days ago

3.) 72 year-old woman with history of asthma with HR 90 and is due for her beta-blocker 4.) 48 year-old man admitted with cellulitis of his right hand after a construction accident, currently on IV antibiotics, with a temperature of 101.8 Correct Answer 4 Cellulitis is serious infection, involving swelling of subcutaneous tissue, fluid displacement due to 3rd spacing. What else would you assess? You are assigned to care for a 58 year-old man who is scheduled for a cardiac angiogram during your shift. What actions should you take? Check all that apply. 1 - Explain that the patient will receive short-acting anesthesia 2 - Review the patient's allergies, specifically checking to see if he has an allergy to contrast dye 3 - Inform the patient that his wife should stay at home until the procedure is finished, as family members often distract the team in the cath lab 4 - Review and reconcile his medications. Confirm that he did not take his warfarin 5 - Check the patient's most recent labs paying particular attention to the PT INR Correct Answer 2, 4, 5 Contrast dyes contain iodine and allergy could lead to anaphylactic response; might receive light sedation but needs to be awake and able to follow directions A 62 year-old man, who is s/p coronary artery bypass surgery, is about to be transferred from the ICU to the cardiac stepdown unit. What is the most effective way for the ICU (reporting) nurse and cardiac stepdown

(receiving) nurse to ensure that essential patient information is conveyed? 1 - A face-to-face verbal report with both nurses present in a quiet room 2 - The ICU nurse will provide an audio-recorded report for future reference and documentation 3 - The ICU nurse will document essential transfer information in the patient's medical record 4 - The ICU nurse will accompany the patient to the stepdown unit and provide a face-to-face report, using a unit-approved, standardized guide Correct Answer 4 What is the most common outcome associated with poorly managed hospital discharge? Correct Answer Adverse Drug events The nurse is tracking data on a group of patients with heart failure, who have been discharged from the unit where you work and are now being followed in clinic. What is the best indicator that the nursing interventions of monitoring and teaching have been effective? 1 - Eighty-five percent of patients have not gained weight 2 - Seventy-five percent of family caregivers have reported watching an educational DVD 3 - Five percent of patients have been readmitted to the hospital in the last 90 days 4 - Eighty percent report that they are taking their medications Correct Answer 3 All are important but lower resource utilization is best indicator and one used by accrediting agencies, payors, etc.

You are the nurse preparing to discharge a 46 year-old man with hypertension who was started on chlorothiazide. You ask the patient to share with you his understanding of his new medication. Which of the following statements indicates your teaching has been effective? Select all that apply. 1 - I will weigh myself every day at the same time. 2 - I will notify Charles, the nurse practitioner in my primary care doctor's office if I gain 3 pounds or more, have increased swelling in my feet and ankles, or feel more tired than usual. 3 - I will reduce my medication if I feel very thirsty or dizzy. 4 - I will wear sunscreen if I will be out in the sun for a long period of time. 5 - If I want to drink alcohol, I will wait and take my medication right before I go to bed. Correct Answer 1, 2, 4 The following should NOT be used to reduce pressure, as it may increase friction injuries: A) rolled towels B) convoluted foam mattress overlay C) foam pads D) viscoelastic overlay Correct Answer A Rolled towels and sheets should not be used and may negate pressure-reducing function of other pads The MOST common cause of delayed surgical wound healing is: A) diabetes B) surgical site infection

C) malnutrition D) impaired circulation Correct Answer B Purlent discharge, signs of infection, open wound. Can occur <30 days up to 1 year post op An adult Jehovah's' Witness patient is hemorrhaging and might die without transfusions, but he refused blood products prior to surgery. The correct procedure is? A) use volume replacement and fractionated blood cells only, as permitted by the religion B) contact family and ask permission C) ask legal authorities to grant permission D) give transfusions because the patient may die Correct Answer ANSWER: A This patients religion only permits fractions from red cells, white cells, platelets, and plasma. Some JW request no blood products at all The nurse is taking care of Ms. Smith. She is a 85 year old with severe congestive heart failure and has history of severe dementia and CVA. She has had multiple admissions for CHF exacerbation. Despite aggressive treatment, she remains dyspneic and is requiring high flow oxygen at 10L. During rounds, the team discusses sending the patient to the ICU due to her probable need for mechanical ventilation. As the nurse you are concerned that this plan of care is inappropriate, what is the best action?

A. Discuss the concern with the physician and treatment team and recommend consultation with palliative care B. Call the patient's proxy and schedule a meeting with the physician C. Initiate an ethics consult immediately D. Communicate the concerns to the oncoming nurse during hand off of care Correct Answer A Jill Green is a 42-year-old mother of two who has been married for 17 years. She was diagnosed with ovarian cancer 2 years ago. After the initial diagnosis Jill had a total hysterectomy. For the last 2 years she has undergone intensive chemotherapy and radiation. Despite treatment, the ovarian cancer progressed to the late stage and metastasized to the lungs and bones. After collaborating with her healthcare providers, Jill has decided to pursue palliative care with a focus on comfort care.The home hospice RN is assigned to manage Jill's care. During the initial evaluation, the RN establishes a plan of care. Which problem should the nurse address first? A. The client's bowel and urination elimination pattern, the priority concern of the health care provider. B. The problem that the client identifies as the first priority, the problem that most concerns the client. C. The client's need for help with hygienic activit Correct Answer B When Jill is awake, she often seems restless and begins to pull and pick at the bed linen. Jill's sister has concerns

about managing her restlessness at home. She asks the nurse if there are non-pharmacological interventions that their family can try. Which interventions for restlessness should the RN encourage Jill's family to try? A. Keep the lights in Jill's room dimmed. B. Read a favorite poem or passage aloud. C. Apply restraints to prevent injury D. Gently rub back or stroke arms E. Play soothing music F. Avoid talking when at the bedside. Correct Answer A, B, D, E Jill says that she felt like she was stamped with an "expiration date" when her physician told her she had 4- 6 months to live. She explains to Stacy that she feels overwhelmed because there is so much she still wants to teach her children before she dies. Which intervention should the nurse implement? A. Urge the client not to give up hope because a curse is always a possibility. B. Encourage the client to focus on herself for now and to try not to worry about the children. C. Ask the client if she is interested in having a volunteer help her record her thoughts. D. Assure the client that her husband will be there for the children when she is not. Correct Answer C The nurse is managing the hospice care for the patient (Jill) and her family. Over the next 2 months Jill's physical

condition deteriorates and she is unable to get out of bed. Her sister chooses to sleep in a recliner at her bedside. She explains to the nurse that Jill wakes up in the middle of the night in pain, but she is afraid that if she gives Jill pain medication then she might not wake up in the morning. How should the nurse respond to the sister's concerns? A. It is impossible to overdose a client who is dying of cancer because they have built up a tolerance to the medication B. We can collaborate with the primary healthcare provider to try to find a dose of pain medication that works for Jill. C. It is very difficult for clients with terminal cancer to have all of their pain relieved, so Jill may have to endure pain during the night. D. You may give Jill pain medication anytime unless her respirations ar Correct Answer B According to the Institute of Medicine Report (IOM) in 2001 there are 6 core ingredients of high quality health care. Which of the following is (are) NOT on that list? (Check all that apply). A. Patient-centered care B. Highly specialized care delivered exclusively in specialty care clinics C. Care that emphasizes patient safety

D. Efficiency E. Care provided exclusively by physician-led teams Correct Answer B, E According to Kitson et al., the following are common core elements of patient centered care (PCC) across health policy, medicine and nursing disciplines. (Check all that apply) A. Patient and family member involvement B. Policies and an environment that support PCC C. Requirement that all patients complete advance directives D. Open, effective communication between patient and provider and among members of health care team E. A "zero tolerance" policy for deviations from established protocols, policies, and procedures Correct Answer A, B, D Kitson and colleagues concluded that although there was consensus around some facets of PCC, there were differences among the disciplines with respect to areas of focus on PCC. Which statement best summarizes the unique focus of nursing as it applies to PCC?

A. Primary importance on the individual nurse-patient relationship B. Personal qualities such as politeness, being respectful, and having good manners, are more important than competence in delivering patient care C. Focus on the patient, not on the caregiver or family members D. Protecting the patient from interference by other disciplines E. The need for a systematic and comprehensive assessment of patient needs and respect for patient values and preferences Correct Answer E ased on the readings and your experience to-date, which of the following concepts are essential to patient-centered care planning? (Check all that apply) A. The nurse is the sole expert in the care planning process B. Respect and dignity are foundational to the care planning process; including honoring patient perspectives, values, beliefs, choices, cultural background C. Communication that is timely, transparent, accurate and complete among all members of the health care team

D. If patients are non-compliant with care recommendations it is always due to a knowledge deficit on their part E. The patient and family are essential members of the health care team and should be included in the assessment, planning, execution and evaluation of care Correct Answer B, C, E Which of the following are examples of transitions in care (TC)? (Check all that apply). A. Patient is admitted to the hospital from home B. Patient is transferred from the Cardiac Intensive Care Unit to a general medical floor within the same hospital C. Nursing change of shift D. Patient is discharged home E. Patient is transferred to a skilled nursing facility for rehab following a hip replacement. Correct Answer A, B, C, D, E Why has TC emerged as a high priority area in health care reform? A. Hospitals want to reduce the number of lawsuits B. Insurance companies are reluctant to advocate for safe, effective TC

C. Effective management of TC has the potential to reduce the cost and improve the quality of health care D. Physician groups are advocating for the creation of a physician sub-specialty designed to manage TC Correct Answer C According to Coleman (2003), which of the following are components of effective TCs? (Check all that apply) A. A detailed follow-up plan B. Effective written and oral communication among health care providers within and across settings C. Medication reconciliation D. Comprehensive patient/caregiver teaching/education E. Each care provider having his/her own specific care plan that addresses only their unique concerns for that patient Correct Answer A, B, C, D In order to manage TCs effectively which of the following are important to include in the teaching plan for the patient? (Check all that apply) A. Signs indicating that the patient's situation has deteriorated and warrants further intervention B. The names, roles, and contact information for who to contact for problems or concerns

C. What to expect upon transfer, discharge, or next site of care D. Including family members and/or informal caregivers in the teaching plan E. Instructions for any follow-up care, such as lab work, tests or procedures, appointments Correct Answer A, B, C, ,D, E Which of the following are barriers to effective management of TCs? (Check all that apply) A. Frequent exclusion of patients and caregivers as participants in care planning B. Growing reliance of institution-based care providers C. Lack of professional training in skills needed to effectively manage TCs D. Electronic medical records designed to be shared among various providers and care settings E. Lack of formal, standardized methods of communicating across care settings Correct Answer A, B, C, E Which of the following adverse events are associated with ineffective management of TCs? (Check all that apply).

A. Higher hospital readmission rates B. Medication errors C. Failure of patient to seek attention for worsening condition D. Increased stress and burden on caregivers E. Decreased satisfaction among patients, caregivers or family members, and health care providers Correct Answer A, B, C, D, E Which of the following are potential adverse outcomes of ineffective nurse care handovers? Check all that apply. A. Delays in diagnosis B. Increased cost and length of stay C. Patient dissatisfaction D. Nurse's inability to appropriately anticipate future patient events E. Nursing care based on inaccurate or incomplete information Correct Answer A, B, C, D, E The majority of adverse events during transitions of care (TCs) are related to which of the following issues? A. Family members refusal to be involved in patient care B. Ineffective communication and information among caregivers

C. Inaccuracy of patient provided information D. Lack of willingness of disciplines to work collaboratively E. Insurance companies' reimbursement policies Correct Answer B According to Holly and Poletick, aside from conveying patient information what other purpose does shift report or intershift handover of care serve? Check all that apply. A. Provides nurses with opportunities to provide and receive support from colleagues B. Increases team cohesion by through social interactions that lead to shared values and development of a group identity C. Provides nurses an opportunity to gossip about other members of the health care team D. Provide a venue to orient new nurses to the unit culture E. Provide opportunities for nurses to develop workarounds of unit policies they don't like Correct Answer A, B, D

Which characteristics of patient care handovers or TCs were most consistently related to adverse outcomes? Check all that apply. A. Inconsistency in content included B. Lack of respect for the roles of other disciplines C. Unstructured format D. Including health care providers outside of nursing in information exchange E. Variability in patient health literacy levels Correct Answer A, C According to Ong et al., what challenges are unique to intrahospital transfers (versus intershift handover)? Check all that apply A. The coordination effort required in patient transportation B. The difficulty in sharing information across disciplines and departments C. Lack of standardization in the content and process of information sharing D. Lack of training on handover practices and communication skills