Chapter 67 Acute Respiratory Failure and Acute Respiraratory Question and answers already, Exams of Nursing

Download Chapter 67 Acute Respiratory Failure and Acute Respiraratory Question and answers already and more Exams Nursing in PDF only on Docsity! Chapter 67: Acute Respiratory Failure and Acute Respiratory Distress Syndrome 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 - correct answer C. Arterial blood gas analysis 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 degrees. E. Provide oral care daily with chlorhexidine (0.12%) solution. - correct answer B. Provide a "sedation holiday" daily. C. Give prescribed pantoprazole (Protonix). D. Elevate the head of the bed to at least 30 degrees. E. Provide oral care daily with chlorhexidine (0.12%) solution. 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 flowrate. c. Teach the patient to cough and deep breathe. d. Help the patient to sit in a more upright position. - correct answer b. Increase the prescribed O2 flowrate. 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 - correct answer B. Albumin level and weight loss A patient with respiratory failure has a respiratory rate of 6 breaths/min and an oxygen saturation (SpO2) of 78%. 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) - correct answer B. Endotracheal intubation and positive pressure ventilation 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. C. Sucralfate (Carafate) 1 gram per NG tube D. Methylprednisolone (Solu-Medrol) 60 mg IV - correct answer A. Gentamicin 60 mg IV 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/VN) 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. - correct answer D. Insert an indwelling urinary catheter. A patient develops increasing dyspnea and hypoxemia 2 days after heart surgery. What procedure should the nurse anticipate assisting with to determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by heart failure? 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 - correct answer D. Insertion of a pulmonary artery catheter 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 non-rebreather mask. D. Temperature 101.5° F (38.6° C) after 2 days of IV antibiotics. - correct answer C. Oxygen saturation 90% on 100% O2 by non-rebreather mask. 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 - correct answer B. The patient has subcutaneous emphysema on the upper thorax. 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. - correct answer 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. 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." - correct answer B. "PEEP prevents the lung air sacs from collapsing during exhalation." The nurse observes a new onset of agitation and confusion in a patient with chronic obstructive pulmonary disease (COPD). 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. - correct answer D. Assess oxygenation using pulse oximetry. Prone positioning is being 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. - correct answer A. The patient's PaO2 is 89 mm Hg, and the SaO2 is 91%. A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department reporting shortness of breath 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 respiratory rate is 10 breaths/min. D. The patient's pulse oximetry shows a 91% O2 saturation. - correct answer C. The patient's respiratory rate is 10 breaths/min. 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?