Exam 2 ARDS RF (NCLEX) Question and answers correctly solved, Exams of Nursing

Download Exam 2 ARDS RF (NCLEX) Question and answers correctly solved and more Exams Nursing in PDF only on Docsity! Exam 2: ARDS/RF (NCLEX) The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress sysndrome? a. Bilateral wheezing b. Inspiratory crackles c. Intercostal retractions d. Increased respiratory rate - correct answer D When assessing a 22-year-old patient who required emergency surgery and multiple transfusions 3 days ago, the nurse finds that the patient looks anxious and has labored respirations at a rate of 38 breaths/min. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most appropriate? A.) Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes. B.) Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs. C.) Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation. D.)Switch the patient to a nonrebreather mask at 95% to 100% fraction of inspired oxygen (FIO2) and call the health care provider to discuss the patient's status. - correct answer D The patient's history and symptoms suggest the development of acute respiratory distress syndrome (ARDS), which will require intubation and mechanical ventilation to maintain oxygenation and gas exchange. The HCP must be notified so that appropriate interventions can be taken. Application of a nonrebreather mask can improve oxygenation up to 95 to 100%. The maximum oxygen delivery with a nasal cannula is an Fio2 of 44%. This is achieved with the oxygen flow at 6 L/min, so increasing the flow to 10 L/min will not be helpful. Helping the patient to cough and deep breathe will not improve the lung stiffness that is causing his respiratory distress. Morphine sulfate will only decrease the respiratory drive and further contribute to his hypoxemia. The nurse is caring for a patient with emphysema and respiratory failure who is receiving mechanical ventilation through an endotracheal tube. To prevent ventilator-associated pneumonia (VAP), which action is most important to include in the plan of care? A.) Administer ordered antibiotics as scheduled. B.) Hyperoxygenate the patient before suctioning. C.) Maintain the head of bed at a 30- to 45-degree angle. D.) Suction the airway when coarse crackles are audible. - correct answer C The high-pressure alarm on a patient's ventilator goes off. When the nurse enters the room to assess the patient, who has acute respiratory distress syndrome (ARDS), the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should the nurse take first? A.) Reassure the patient that the ventilator will do the work of breathing for him. B.) Manually ventilate the patient while assessing possible reasons for the high-pressure alarm. C.) Increase the fraction of inspired oxygen (Fio2) on the ventilator to 100% in preparation for endotracheal suctioning. D.) Insert an oral airway to prevent the patient from biting on the endotracheal tube. - correct answer B The high-pressure alarm on a patient's ventilator goes off. When the nurse enters the room to assess the patient, who has acute respiratory distress syndrome (ARDS), the oxygen saturation monitor reads 87% and the patient is struggling to sit up. Which action should the nurse take first? a. Reassure the patient that the ventilator will do the work of breathing for him. b. Manually ventilate the patient while assessing possible reasons for the high-pressure alarm. c. Increase the fraction of inspired oxygen (Fio2) on the ventilator to 100% in preparation for endotracheal suctioning. d. Insert an oral airway to prevent the patient from biting on the endotracheal tube. - correct answer B The nurse knows that which of the following conditions would most likely contribute to the development of ARDS? E. Increased response to corticosteroid therapy - correct answer ACD Prone positioning, or placing the patient face down with the head turned to the side, helps with pulmonary function in the patient diagnosed with ARDS. Studies have shown that patients who are positioned prone and who have respiratory conditions often have improved outcomes of decreased lung atelectasis, mobilization of secretions to enhance suctioning, and decreased fluid accumulation in the lung tissue. A 26-year-old patient is admitted to the hospital in severe respiratory distress. His oxygen saturations are 80% despite supplemental oxygen provided by facemask. The physician decides to intubate the patient to help with his breathing oxygenation. Which medication would the nurse most likely administer when assisting with intubation? a. Midazolam (Versed) b. Zolpidem (Ambien) c. Phentermine (Adipex-P) d. Modafinil (Provigil) - correct answer A Intubation is most often performed by inserting a tube into the mouth and passing it into the trachea in order to provide help and support for a patients breathing. Most registered nurses do not perform endotracheal intubation, but they may assist the physician with placing the tube. The nurse may give medications to sedate the patient during the procedure, since it can be traumatic for the patient. Some medications given for sedation include midazolam, fentanyl, and etomidate A male client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm? A. Kinking of the ventilator tubing B. disconnected ventilator tube C. An ET cuff leak D. A change in the oxygen concentration without resetting the oxygen level alarm - correct answer A Conditions that trigger the high-pressure alarm include kinking of the ventilator tubing, bronchospasm or pulmonary embolus, mucus plugging, water in the tube, coughing or biting on the ET tube, and the client's being out of breathing rhythm with the ventilator. A disconnected ventilator tube or an ET cuff leak would trigger the low-pressure alarm. Changing the oxygen concentration without resetting the oxygen level alarm would trigger the oxygen alarm. A firefighter who was involved in extinguishing a house fire is being treated for smoke inhalation. He develops severe hypoxia 48 hours after the incident, requiring intubation and mechanical ventilation. Which of the following conditions has he most likely developed? A. Acute respiratory distress syndrome (ARDS). B. Atelectasis. C. Bronchitis. D. Pneumonia - correct answer A Severe hypoxia after smoke inhalation typically is related to ARDS. The other choices aren't typically associated with smoke inhalation. A nurse is assessing a female client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse assesses for which earliest sign of acute respiratory distress syndrome? A. Bilateral wheezing B. Inspiratory Crackles C. Intercostal retractions D. Increased respiratory rate - correct answer D The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles. A nurse is taking pulmonary artery catheter measurements of a male client with acute respiratory distress syndrome. The pulmonary capillary wedge pressure reading is 12mm Hg. The nurse interprets that this readings is: A. High and expected B. Low and unexpected C. Normal and expected D. Uncertain and unexpected - correct answer C The normal pulmonary capillary wedge pressure (PCWP) is 8 to 13 mm Hg, and the client is considered to have high readings if they exceed 18 to 20 mm Hg. The client with acute respiratory distress syndrome has a normal PCWP, which is an expected finding because the edema is in the interstitium of the lung and is noncardiac. Which of the following are the 5 characteristics of ARDS? A. Dyspnea B. Myasthenia Gravis C. Refractory hypoxemia D. Cyanosis E. Dense pulmonary infiltrates on CXR F. Decreased pulmonary compliance G. Non-cardiac pulmonary edema H. Chest pain - correct answer ACEFG Acute Respiratory Distress Syndrome (ARDS) can be defined as _____________________________. A. Sudden life-threatening deterioration of gas exchange in the lungs B. Non-cardiac pulmonary edema with increasing hypoxemia despite treatment with O2 C. Sudden life-threatening pulmonary edema that causes a deterioration of gas exchange despite treatment with O2 - correct answer B The client diagnosed with ARDS is transferred to the intensive care department and placed on a ventilator. Which intervention should the nurse implement first? 1. Confirm that they ventilator settings are correct 2. Verify that the ventilator alarms are functioning properly 3. Request STAT ABGs 4. Auscultate the client's lung sounds - correct answer 2 The nurse is caring for a client diagnosed with ARDS. Which interventions should the nurse implement? Select All that Apply 1. Assess the client's level of consciousness 2. Monitor urine output every shift 3. Turn the client every 2 hours 4. Maintain intravenous fluids as ordered 5. Place the client in the Fowler's position - correct answer 1345 Which instruction is priority for the nurse to discuss with the client diagnosed with ARDS who is being discharged from the hospital? 1. Avoid smoking and exposure to smoke 2. Do not receive flu or pneumonia vaccines 3. Avoid any type of alcohol intake 4. It will take about one month to recuperate - correct answer 1 The client diagnosed with ARDS is on a ventilator and the high alarm indicates an increase in the peak airway pressure. Which intervention should the nurse implement first? 1. Check the tubing for any kinks 2. Suction the airway for secretion 3. Assess the lip line of the ET tube 4. Sedate the client with a muscle relaxant - correct answer 1 To evaluate the effectiveness of prescribed therapies for a patient with ventilatory failure, which diagnostic test will be most useful to the nurse? a. Chest x-rays b. Pulse oximetry c. Arterial blood gas (ABG) analysis d. Pulmonary artery pressure monitoring - correct answer C A patient with respiratory failure has a respiratory rate of 8 and an SpO2 of 89%. The patient is increasingly lethargic. The nurse will anticipate assisting with a. administration of 100% oxygen by non-rebreather mask. b. endotracheal intubation and positive pressure ventilation. c. insertion of a mini-tracheostomy with frequent suctioning. d. initiation of bilevel positive pressure ventilation (BiPAP). - correct answer B The patient's lethargy, low respiratory rate, and SpO2 indicate the need for mechanical ventilation with ventilator-controlled respiratory rate. Administration of high flow oxygen will not be helpful because the patient's respiratory rate is so low. Insertion of a mini-tracheostomy will facilitate removal of secretions, but it will not improve the patient's respiratory rate or oxygenation. BiPAP requires that the patient initiate an adequate respiratory rate to allow adequate gas exchange. When admitting a patient in possible respiratory failure with a high PaCO2, which assessment information will be of most concern to the nurse? a. The patient is somnolent. b. The patient's SpO2 is 90%. c. The patient complains of weakness. d. The patient's blood pressure is 162/94. - correct answer A Increasing somnolence will decrease the patient's respiratory rate and further increase the PaCO2 and respiratory failure. Rapid action is needed to prevent respiratory arrest. An SpO2 of 90%, weakness, and elevated blood pressure all require ongoing monitoring but are not indicators of possible impending respiratory arrest. A patient with acute respiratory distress syndrome (ARDS) and acute renal failure has the following medications prescribed. Which medication should the nurse discuss with the health care provider before administration? a. ranitidine (Zantac) 50 mg IV b. gentamicin (Garamycin) 60 mg IV c. sucralfate (Carafate) 1 g per nasogastric tubed. d. methylprednisolone (Solu-Medrol) 40 mg IV - correct answer B Gentamicin, which is one of the aminoglycoside antibiotics, is potentially nephrotoxic, and the nurse should clarify the drug and dosage with the health care provider before administration. The other medications are appropriate for the patient with ARDS. A patient develops increasing dyspnea and hypoxemia 2 days after having cardiac surgery. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by left ventricular failure, the nurse will anticipate assisting with a. inserting a pulmonary artery catheter. b. obtaining a ventilation-perfusion scan. c. drawing blood for arterial blood gases. d. positioning the patient for a chest radiograph. - correct answer A Pulmonary artery wedge pressures are normal in the patient with ARDS because the fluid in the alveoli is caused by increased permeability of the alveolar-capillary membrane rather than by the backup of fluid from the lungs (as occurs in cardiogenic pulmonary edema). The other tests will not help in differentiating cardiogenic from noncardiogenic pulmonary edema. Which assessment finding by the nurse when caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP) indicates that the PEEP may need to be decreased? a. The patient has subcutaneous emphysema. b. The patient has a sinus bradycardia with a rate of 52. c. The patient's PaO2 is 50 mm Hg and the SaO2 is 88%. d. The patient has bronchial breath sounds in both the lung fields. - correct answer A The nurse is caring for a client with suspected acute respiratory distress syndrome (ARDS). Which symptom of ARDS should the nurse anticipate will appear within 24 to 48 hours after the initial insult? (Select all that apply.) A. Shortness of breath B. Rapid breathing C. Arterial blood gases varying from normal limits D. Fluid imbalance E. Chest x-ray clear of infiltrates - correct answer ABE The nurse is caring for a client who had an episode of near-drowning 5 days ago. This morning, the nurse noted rhonchi in the lower lung lobes on auscultation. Which action by the nurse is best? A. Monitoring vital signs and oxygen saturation every 2 hours B. Documenting the findings as normal C. Notifying the healthcare provider D. Preparing for intubation - correct answer C A client is brought into the emergency department after aspirating on pureed foods at the long-term care facility. The nurse knows that which physiologic change can trigger acute respiratory distress syndrome? A. Intracellular edema B. Increased surfactant production C. Destruction of extracellular platelets D. Release of chemical mediators - correct answer D The nurse is caring for a client with respiratory acidosis secondary to end-stage acute respiratory distress syndrome (ARDS). Which result should the nurse anticipate on the arterial blood gas? A. High PaO2 and high PaCO2 B. Low PaO2 and low PaCO2 C. High PaO2 and low PaCO2 D. Low PaO2 and high PaCO2 - correct answer D A pediatric client is not responding to treatment for acute respiratory distress syndrome (ARDS) and requires intubation. The mother is anxious that the procedure will hurt. Which is the best response by the nurse? A. "We will administer medication to help him sleep through the intubation and as needed while he is on the ventilator." B. "He may feel a little nervous, but he will get used to the ventilator soon enough." C. "He will actually feel better and may even like the ventilator because he will be able to breathe more comfortably." D. "Don't worry; intubation and using a ventilator doesn't hurt at all." - correct answer A A pregnant woman has been diagnosed with acute respiratory distress syndrome (ARDS) and prescribed corticosteroids. The woman asks the nurse if it is safe to take this medication. Which is the best reply by the nurse? A. "That is an error; you shouldn't take corticosteroids during pregnancy." B. "Let's call the doctor and pharmacist to double check the safety profile of these drugs." C. "Corticosteroids are safe to take during pregnancy in some cases, and you need the medicine." D. "If the doctor prescribed the medication, I'm sure that it's fine to take it." - correct answer C The nurse is caring for an adult who is diagnosed with acute respiratory distress syndrome (ARDS) after a near-drowning episode last week. Which type of medication should the nurse anticipate the provider ordering to help open alveoli? A. Corticosteroids B. Nonsteroidal anti-inflammatory drugs (NSAIDs) C. Inhaled nitric oxide D. Surfactant therapy - correct answer D During assessment of a client with acute respiratory distress syndrome (ARDS), the nurse notes an oxygen saturation of 78% and a respiratory rate of 28 breaths/min. The nurse notifies the healthcare provider and should prepare for intubation using which type of airway? A. Oropharyngeal airway B. Endotracheal tube C. Tracheostomy D. Nasopharyngeal airway - correct answer B The nurse is assessing an older adult client with acute respiratory distress syndrome (ARDS). Which assessment finding indicates an early sign of hypoxemia for this client?(Select all that apply.) A. Agitation B. Confusion C. Tachypnea D. Dyspnea E. Anxiety - correct answer ABE The nurse is providing care to a client with acute respiratory distress syndrome (ARDS). Which independent intervention should the nurse prepare to perform for this client? (Select all that apply.) A. Order a Foley catheter to monitor urine output. B. Prescribe analgesia for pain. C. Maintain the head of the bed at 30 degrees. D. Recommend a prone position to facilitate oxygenation. E. Auscultate heart and lung sounds. - correct answer CDE Clinical manifestations that occur with hypoxemic respiratory failure include cyanosis, tachypnea, and paradoxic chest or abdominal wall movement with the respiratory cycle. Clinical manifestations of hypercapnic respiratory failure include morning headache, pursed-lip breathing, and decreased or increase respiratory rate with shallow breathing. The oxygen delivery system chosen for the patient in acute respiratory failure should A. always be a low-flow device, such as a nasal cannula. B. correct the PaO2 to a normal level as quickly as possible. C. administer positive-pressure ventilation to prevent CO2 narcosis. D. maintain the PaO2 at ≥60 mm Hg at the lowest O2 concentration possible. - correct answer D You are caring for a patient who is admitted with a barbiturate overdose. The patient is unresponsive, with a blood pressure of 90/60 mm Hg, apical pulse of 110 beats/minute, and respiratory rate of 8 breaths/minute. Based on the initial assessment findings, you recognize that the patient is at risk for which type of respiratory failure? A. Hypoxemic respiratory failure related to shunting of blood B. Hypoxemic respiratory failure related to diffusion limitation C. Hypercapnic respiratory failure related to alveolar hypoventilation D. Hypercapnic respiratory failure related to increased airway resistance - correct answer C Which intervention is key to preventing ventilator-associated pneumonia as a complication in a patient with acute respiratory distress syndrome (ARDS)? A. Scheduled prophylactic nasopharyngeal suctioning B. Instilling normal saline down the endotracheal tube to loosen secretions C. Providing frequent mouth care and oral hygiene D. Using high tidal volumes on the ventilator - correct answer C What pathophysiologic condition can result in ARDS? A. Damage to the alveolar-capillary membrane B. Copious exudates production C. Airway spasms and vasoconstriction D. Change in the inspiratory-to-expiratory ratio - correct answer A Which is a classic finding for a patient with ARDS? A. Hypoxemia despite increased oxygen administration B. Bronchodilators ordered to relieve airway spasms C. Development of Kussmaul respirations D. Development of Cheyne-Stokes respirations - correct answer A Which is part of the nursing management for ARDS? A. Aggressive use of intravenous (IV) fluids B. Administration of a β-blocker C. Use of positive end-expiratory pressure (PEEP) D. Use of the lateral recumbent position - correct answer C What is the classic chest x-ray finding in a patient with late-stage ARDS? A. Hyperinflation B. Infiltrates in the bases C. Deflated lung on one side D. White lung - correct answer D What are the most common early clinical manifestations of ARDS? A. Dyspnea and tachypnea B. Cyanosis and apprehension C. Hypotension and tachycardia D. Respiratory distress and frothy sputum - correct answer A Maintenance of fluid balance in the patient with ARDS involves A. hydration using colloids. B. administration of surfactant. C. mild fluid restriction and diuretics as necessary. D. keeping the hemoglobin level greater than 12 g/dL (120 g/L). - correct answer C A patient has ARDS resulting from sepsis. Which measure is most likely to be implemented to maintain cardiac output? A. Administer crystalloid fluids or colloid solutions. B. Position the patient in the Trendelenburg position. C. Perform chest physiotherapy and assist with staged coughing. D. Place the patient on fluid restriction, and administer diuretics. - correct answer A The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome? 1.Bilateral wheezing 2.Inspiratory crackles 3.Intercostal retractions 4.Increased respiratory rate - correct answer 4