Acute Respiratory Distress Syndrome: Symptoms, Assessment, and Management, Exams of Nursing

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SOLE Chapter 15: Acute Respiratory

Failure TEST BANK Examination test

1. The nurse is caring for a patient with acute respiratory failure and identifies "Risk for Ineffective Airway Clearance" as a nursing diagnosis. A nursing intervention relevant to this
2. diagnosis is to a. elevate the head of the bed to 30 degrees. b. obtain an order for venous thromboembolism prophylaxis. c. provide adequate sedation. d. reposition the patient every 2 hours. - Correct answer ANS: D
3. Repositioning the patient will facilitate mobilization of secretions. Elevating the head of bed
4. is an intervention to prevent infection. Venous thromboembolism prophylaxis is ordered to
5. prevent complications of immobility. Sedation is an intervention to manage anxiety, and
6. administration of sedatives increases the risk for retained secretions.
7. REF: p. 396
8. Sedation is an intervention to _________, and
9. administration of ________ increases the risk for _______. - Correct answer Sedation is an intervention to manage anxiety, and
10. administration of sedatives increases the risk for retained secretions.
11. repositioning helps to ________ - Correct answer mobilize secretions
12. Elevating the HOB is used to prevent _______ - Correct answer infections
13. The patient with acute respiratory distress syndrome (ARDS) would exhibit which of the following symptoms? a. Decreasing PaO2 levels despite increased FiO2 administration b. Elevated alveolar surfactant levels c. Increased lung compliance with increased FiO2 administration d. Respiratory acidosis associated with hyperventilation - Correct answer ANS: A
14. Patients with ARDS often have hypoxemia refractory to treatment. Surfactant levels are often diminished in ARDS. Compliance decreases in ARDS. In early ARDS,
15. hyperventilation may occur along with respiratory alkalosis.
16. DIF: Cognitive Level: Understand/Comprehension REF: pp. 298-

17. OBJ: Describe the pathophysiology of ARF.
18. TOP: Nursing Process Step: Assessment
19. MSC: NCLEX Client Needs Category: Physiological Integrity
20. When fluid is present in the alveoli, a. alveoli collapse, and atelectasis occurs. b. diffusion of oxygen and carbon dioxide is impaired. c. hypoventilation occurs. d. the patient is in heart failure. - Correct answer ANS: B
21. Fluid prevents the diffusion of gases. It does not cause atelectasis or hypoventilation. Fluid
22. can be present in the alveoli secondary to heart failure; however, there are other causes as
23. well, such as acute respiratory distress syndrome.
24. DIF: Cognitive Level: Understand/Comprehension REF: p. 391
25. OBJ: Describe the pathophysiology of ARF.
26. TOP: Nursing Process Step: Assessment
27. MSC: NCLEX Client Needs Category: Physiological Integrity
28. In assessing a patient, the nurse understands that an early sign of hypoxemia is a. clubbing of nail beds. b. cyanosis. c. hypotension. d. restlessness. - Correct answer ANS: D
29. Central nervous system signs, such as restlessness, are early indications of low oxygen
30. levels. Clubbing is a sign of chronic hypoxemia. Cyanosis is a late sign of hypoxemia.
31. Tachycardia and increased blood pressure, not hypotension, may be seen early in
32. hypoxemia.
33. DIF: Cognitive Level: Understand/Comprehension REF: p. 392
34. OBJ: Describe methods for assessing the patient with ARF.
35. TOP: Nursing Process Step: Assessment
36. MSC: NCLEX Client Needs Category: Physiological Integrity
37. The basic underlying pathophysiology of acute respiratory distress syndrome results in a. a decrease in the number of white blood cells available. b. damage to the right mainstem bronchus. c. damage to the type II pneumocytes, which produce surfactant. d. decreased capillary permeability. - Correct answer ANS: C
38. Acute respiratory distress syndrome results in damage to the pneumocytes, increased
39. capillary permeability, and noncardiogenic pulmonary edema.
40. DIF: Cognitive Level: Understand/Comprehension

41. REF: p. 398 | Figure 15-2 OBJ: Describe the pathophysiology of ARF.
42. TOP: Nursing Process Step: Assessment
43. MSC: NCLEX Client Needs Category: Physiological Integrity
44. The nurse is caring for a patient with acute respiratory distress syndrome who is hypoxemic
45. despite mechanical ventilation. The provider prescribes a nontraditional ventilator mode as
46. part of treatment. Despite sedation and analgesia, the patient remains restless and appears to
47. be in discomfort. The nurse informs the provider of this assessment and anticipates an order
48. for a. continuous lateral rotation therapy. b. guided imagery. c. neuromuscular blockade. d. prone positioning. - Correct answer ANS: C
49. Paralysis and additional sedation may be needed if the patient requires nontraditional
50. ventilation. Guided imagery is an excellent nonpharmacological approach to manage
51. anxiety; however, the nontraditional mode of ventilation usually requires that the patient
52. receive neuromuscular blockade. Prone positioning is a treatment for refractory hypoxemia
53. but not indicated to treat this patient, who is restless and appears to be in discomfort.
54. Lateral rotation is not a mode of ventilation; it is used as part of a progressive mobility
55. program for critically ill patients.
56. DIF: Cognitive Level: Analyze/Analysis REF: p. 400
57. OBJ: Discuss medical management of the patient with ARF.
58. TOP: Nursing Process Step: Evaluation
59. MSC: NCLEX Client Needs Category: Physiological Integrity.
60. 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 ANS: C
61. Noninvasive measures are often recommended in the initial treatment of the patient with

62. chronic obstructive pulmonary disease to prevent intubation and ventilator dependence. The
63. history of chronic obstructive pulmonary disease increases the risk for ventilator
64. dependence, so noninvasive options are a priority. Bag-valve ventilation with 100% oxygen
65. is not required at this time and could depress the respiratory drive that exists. Emergency
66. tracheostomy is not indicated, as there is no indication of an obstructed airway.
67. DIF: Cognitive Level: Analyze/Analysis REF: p. 414
68. OBJ: Discuss medical management of the patient with ARF.
69. TOP: Nursing Process Step: Planning
70. MSC: NCLEX Client Needs Category: Physiological Integrity
71. _________ are often recommended in the ______treatment of the patient with __________ to prevent _________.
72. The history of ________ increases the risk for _______, so _______ options are a priority. - Correct answer Noninvasive measures are often recommended in the initial treatment of the patient with
73. chronic obstructive pulmonary disease to prevent intubation and ventilator dependence. The
74. history of chronic obstructive pulmonary disease increases the risk for ventilator
75. dependence, so noninvasive options are a priority.
76. 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 ANS: C
77. Although the patient with a severe exacerbation of asthma hyperventilates, gas exchange is
78. impaired, which causes respiratory acidosis.
79. DIF: Cognitive Level: Understand/Comprehension REF: p. 404
80. OBJ: Describe the pathophysiology of ARF.
81. TOP: Nursing Process Step: Assessment
82. MSC: NCLEX Client Needs Category: Physiological Integrity
83. 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 ANS: B
84. Inhaled bronchodilators and intravenous corticosteroids are standard treatment for the

85. exacerbation of asthma; they promote dilation of the bronchioles and decreased
86. inflammation of the airways. Proning and continuous lateral rotation are therapies to treat
87. hypoxemia secondary to acute respiratory distress syndrome. Sedation is not recommended.
88. DIF: Cognitive Level: Understand/Comprehension REF: p. 403
89. OBJ: Discuss medical management of the patient with ARF.
90. TOP: Nursing Process Step: Implementation
91. MSC: NCLEX Client Needs Category: Physiological Integrity
92. The nurse is discharging a patient home following treatment for community- acquired
93. 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
94. pneumonia."
95. c. "Stay away from cold, drafty places because that increases your risk of pneumonia
96. when you get home."
97. d. "Since you have been treated for pneumonia, you now have immunity from getting
98. it in the future." - Correct answer ANS: B
99. The influenza vaccine reduces the risk of pneumonia by more than 50%. The pneumococcal
100. vaccine is important but protects only against pneumococcal infection. Cold, drafty
101. environments will not cause infection. Immunity for pneumonia does not occur as a result of
102. getting it.
103. DIF: Cognitive Level: Analyze/Analysis REF: p. 406
104. OBJ: Formulate a plan of care for the patient with ARF.
105. TOP: Nursing Process Step: Implementation
106. MSC: NCLEX Client Needs Category: Physiological Integrity
107. PNA sxs norm and for the elderly - Correct answer fever, cough, dyspnea, tachnypnea,purulent sputum, hemoptyis, WBC greater 15K, pleuritic chest pain, auscultate crackles and rhonchi
108. PNA dx studies - Correct answer CXR show local or diffuse infiltrates,
109. CS cultures
110. abg = hypoxemia and hypocap
111. The nurse is discharging a patient with asthma. As part of the discharge instruction, the

112. nurse instructs the patient to prevent exacerbation by: a. obtaining an appointment for follow-up pulmonary function studies 1 week after
113. discharge.
114. b. limiting activity until the patient is able to climb two flights of stairs.
115. c. taking all asthma medications as prescribed.
116. d. taking medications on a "prn" basis according to symptoms. - Correct answer ANS: C
117. Exacerbation of asthma is often related to not adhering to the therapeutic regimen; patient
118. teaching is essential. Follow-up studies will be determined by the physician. Activity is
119. based on the patient's activity tolerance and is not limited. Medications are taken regularly
120. to avoid exacerbation. Only rescue medications are used on a prn basis.
121. DIF: Cognitive Level: Analyze/Analysis REF: p. 405
122. OBJ: Formulate a plan of care for the patient with ARF.
123. TOP: Nursing Process Step: Implementation
124. MSC: NCLEX Client Needs Category: Physiological Integrity
125. The nurse is caring for a postoperative patient with chronic obstructive pulmonary disease
126. (COPD). Which assessment would be a cue to the patient developing postoperative
127. pneumonia? a. Bradycardia b. Change in sputum characteristics c. Hypoventilation and respiratory acidosis d. Pursed-lip breathing - Correct answer ANS: B
128. Change in the character of sputum may signal the development of a respiratory infection in
129. the patient with COPD. Additional symptoms include anxiety, wheezing, chest tightness,
130. tachypnea, tachycardia, fatigue, malaise, confusion, fever, and sleeping difficulties.
131. DIF: Cognitive Level: Analyze/Analysis REF: p. 402
132. OBJ: Formulate a plan of care for the patient with ARF.
133. TOP: Nursing Process Step: Assessment
134. MSC: NCLEX Client Needs Category: Physiological Integrity
135. The nurse is caring for a patient with a diagnosis of pulmonary embolism. The nurse
136. 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 ANS: B

137. The most common cause of a pulmonary embolus is deep vein thrombosis. The other
138. responses are less common causes.
139. DIF: Cognitive Level: Remember/Knowledge REF: p. 410
140. OBJ: Describe methods for assessing the patient with ARF.
141. TOP: Nursing Process Step: Assessment
142. MSC: NCLEX Client Needs Category: Physiological Integrity
143. The nurse is concerned that a patient is at increased risk of developing a pulmonary embolus
144. 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 ANS: D
145. Mobility helps to prevent deep vein thrombosis and pulmonary embolus. Oral care, head of
146. bed elevation, and coughing and deep breathing assist in preventing pneumonia.
147. DIF: Cognitive Level: Apply/Application REF: p. 411 | Box 15-
148. OBJ: Formulate a plan of care for the patient with ARF.
149. TOP: Nursing Process Step: Planning
150. MSC: NCLEX Client Needs Category: Physiological Integrity
151. _______ helps to prevent ______ and __________. - Correct answer Mobility helps to prevent deep vein thrombosis and pulmonary embolus.
152. _______, ________, _______, assist in preventing pneumonia. - Correct answer Oral care, head of bed elevation, and coughing and deep breathing assist in preventing pneumonia.
153. What helps prevent pneumonia? - Correct answer oral care, elevate HOB, coughing and deep breathing
154. 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 ANS: A

155. PE should be suspected in any patient who has unexplained cardiorespiratory complaints
156. and risk factors for VTE. Dyspnea, hemoptysis, and chest pain have been called the
157. "classic" signs and symptoms for PE, but the three signs and symptoms actually occur in
158. less than 20% of cases. Bradycardia and hyperventilation are not classic signs of PE. Most
159. critically ill patients are at high risk for VTE, and all should receive prophylaxis.
160. REF: p. 411 | Box 15-
161. Most critically ill patients are at _________, and all should receive ________. - Correct answer Most
162. critically ill patients are at high risk for VTE, and all should receive prophylaxis.
163. _____, _______, and _______ have been called the
164. "classic" signs and symptoms for PE, but the three signs and symptoms actually occur in
165. less than ____%of cases. - Correct answer Dyspnea, hemoptysis, and chest pain have been called the
166. "classic" signs and symptoms for PE, but the three signs and symptoms actually occur in
167. less than 20% of cases.
168. A patient at high risk for pulmonary embolism is receiving enoxaparin. The nurse explains
169. to the patient: a. "I'm going to contact the pharmacist to see if you can take this medication by
170. mouth."
171. b. "This injection is being given to prevent blood clots from forming."
172. c. "This medication will dissolve any blood clots you might get."
173. d. "You should not be receiving this medication. I will contact the provider to get it
174. stopped." - Correct answer ANS: B
175. Enoxaparin, or low-molecular weight heparin, is recommended for patients at high risk for
176. PE. This patient is at high risk and the medication is indicated. It is given subcutaneously,
177. not by mouth. The drug prevents clots from forming but does not dissolve them.

178. DIF: Cognitive Level: Apply/Application REF: p. 411 | Box 15-
179. OBJ: Discuss medical management of the patient with ARF.
180. TOP: Nursing Process Step: Assessment
181. MSC: NCLEX Client Needs Category: Physiological Integrity
182. 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 ANS: C
183. The angiogram is one test that can confirm pulmonary embolism. A spiral CT scan is the
184. other definitive test. Both tests have the limitation of not always being able to visualize
185. small emboli in distal vessels. ABG would indicate only hypoxemia and/or acid-base
186. abnormalities. A chest x-ray study is inconclusive. A ventilation-perfusion scan is
187. inconclusive.
188. DIF: Cognitive Level: Understand/Comprehension REF: p. 412
189. OBJ: Discuss medical management of the patient with ARF.
190. TOP: Nursing Process Step: Assessment
191. MSC: NCLEX Client Needs Category: Physiological Integrity
192. What does an ABG test for? - Correct answer ABG would indicate only hypoxemia and/or acid-base
193. abnormalities.
194. Tests to confirm PE and their limitations - Correct answer spiral CT and pulmonary angiogram. Cannot visualize small clots in distal vessels.
195. 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 ANS: C
196. A filter may be inserted as a prevention measure in patients who are at high risk for
197. pulmonary embolism. Aspirin is not a preventive therapy. Thrombolytics are given to treat,
198. not prevent, pulmonary embolism. Heparin is administered as a prophylaxis in acute care

199. settings. Coumadin is given for long-term prevention in patients at high risk for VTE.
200. DIF: Cognitive Level: Apply/Application REF: p. 412
201. OBJ: Discuss medical management of the patient with ARF.
202. TOP: Nursing Process Step: Implementation
203. MSC: NCLEX Client Needs Category: Physiological Integrity
204. 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 ANS: B
205. Increased peak inspiratory pressures are often early indicators of ARDS. Oxygen saturation
206. decreases in ARDS. Chest x-ray study will show progressive infiltrates. In ARDS, a
207. PaO2/FiO2 ratio of less than 200 is a criterion.
208. DIF: Cognitive Level: Apply/Application REF: p. 399
209. OBJ: Describe methods for assessing the patient with ARF.
210. TOP: Nursing Process Step: Assessment
211. MSC: NCLEX Client Needs Category: Physiological Integrity
212. ___________ often early indicators of ARDS.
213. What are the dx of ARDS? - Correct answer Increased peak inspiratory pressures are often early indicators of ARDS. Oxygen saturation
214. decreases in ARDS. Chest x-ray study will show progressive infiltrates. In ARDS, a
215. PaO2/FiO2 ratio of less than 200 is a criterion.
216. The nurse calculates the PaO2/FiO2 ratio for the following values: PaO2 is 78 mm Hg; FiO
217. 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 ANS: B
218. 78/0.60 = 130, which meets the criteria for ARDS.
219. DIF: Cognitive Level: Analyze/Analysis REF: p. 396 Nursing Care Plan
220. OBJ: Describe methods for assessing the patient with ARF.
221. TOP: Nursing Process Step: Assessment
222. MSC: NCLEX Client Needs Category: Physiological Integrity

223. 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 ANS: B
224. A normal PAOP with hypoxemia is an expected assessment finding in ARDS although this
225. has been deleted from the most current definition. Cardiac output of 10 L/min and low
226. systemic vascular resistance are expected findings in sepsis. PAOP of 20 mm Hg and
227. cardiac output of 3 L/min are expected findings in heart failure. PAOP of 5 mm Hg and high
228. systemic vascular resistance are expected findings in hypovolemic shock.
229. DIF: Cognitive Level: Analyze/Analysis REF: p. 396 Nursing Care Plan
230. OBJ: Describe methods for assessing the patient with ARF.
231. TOP: Nursing Process Step: Assessment
232. MSC: NCLEX Client Needs Category: Physiological Integrity
233. The nurse is caring for a patient who is being turned prone as part of treatment for acute
234. respiratory distress syndrome. The nurse understands that the priority nursing concern for
235. 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 ANS: A
236. All are important, but protection of the airway is the most important intervention if the
237. patient is placed in the prone position.
238. DIF: Cognitive Level: Understand/Comprehension REF: p. 400
239. OBJ: Describe the pathophysiology of ARF.
240. TOP: Nursing Process Step: Assessment
241. MSC: NCLEX Client Needs Category: Physiological Integrity
242. During rounds, the provider alerts the team that proning is being considered for a patient
243. 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 ANS: A

244. Proning is considered to improve ventilation by shifting perfusion from the posterior bases
245. of the lung to the anterior portion. The patient is not responding to treatment, and all options
246. should be considered. The patient remains at risk for skin breakdown due to immobility;
247. during proning, the risk is in the dependent areas, such as the face. Proning is a
248. labor-intensive procedure, and the nurse needs help from team members to ensure a safe
249. turn, including protection of the airway. Continuous lateral rotation is a therapy done in the
250. supine position with a specialized bed.
251. DIF: Cognitive Level: Apply/Application REF: p. 400
252. OBJ: Discuss medical management of the patient with acute respiratory failure.
253. TOP: Nursing Process Step: Intervention
254. MSC: NCLEX Client Needs Category: Physiological Integrity
255. The etiology of noncardiogenic pulmonary edema in acute respiratory distress syndrome
256. (ARDS) is related to damage to the a. alveolar-capillary membrane. b. left ventricle. c. mainstem bronchus. d. trachea. - Correct answer ANS: A
257. Damage to the alveolar-capillary membrane results in noncardiogenic pulmonary edema.
258. None of the other responses apply.
259. DIF: Cognitive Level: Understand/Comprehension REF: p. 397
260. OBJ: Describe the pathophysiology of ARF.
261. TOP: Nursing Process Step: Assessment
262. MSC: NCLEX Client Needs Category: Physiological Integrity
263. 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 ANS: A, C
264. Diagnostic criteria for ARDS include bilateral infiltrates, or "white out," on chest x-ray
265. study and a low PaO2/FiO2 ratio. Decreased cardiac output and a high PAOP are seen in

266. pulmonary edema associated with cardiac causes. The PAOP description was deleted from
267. the current definition.
268. DIF: Cognitive Level: Remember/Knowledge REF: pp. 396-
269. OBJ: Formulate a plan of care for the patient with ARF.
270. TOP: Nursing Process Step: Implementation
271. MSC: NCLEX Client Needs Category: Physiological Integrity
272. Which of the following statements is true regarding oral care for the prevention of
273. 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
274. VAP.
275. c. Oral care protocols should include oral suctioning and brushing teeth.
276. d. Protocols that include chlorhexidine gluconate have been effective in preventing
277. VAP.
278. e. Using oral swabs or toothettes are just as effective as brushing the teeth. - Correct answer ANS: B, C, D
279. A comprehensive oral care protocol is an intervention for preventing VAP. It includes oral
280. suction, brushing teeth every 12 hours, and swabbing. Chlorhexidine gluconate has been
281. effective in patients who have undergone cardiac surgery. Actual toothbrushing is vital to
282. the VAP bundle.
283. DIF: Cognitive Level: Apply/Application REF: Box 15-
284. OBJ: Formulate a plan of care for the patient with ARF.
285. TOP: Nursing Process Step: Planning
286. MSC: NCLEX Client Needs Category: Physiological Integrity
287. Which of the following are physiological effects of positive end-expiratory pressure (PEEP)
288. 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 ANS: A, B, C, D
289. Ventilatory support for ARDS typically includes PEEP to restore functional residual
290. capacity, open collapsed alveoli, prevent collapse of unstable alveoli, and improve arterial
291. oxygenation. PEEP does not improve CO2 retention.

292. DIF: Cognitive Level: Understand/Comprehension REF: p. 400
293. OBJ: Discuss medical management of the patient with ARF.
294. TOP: Nursing Process Step: Implementation
295. MSC: NCLEX Client Needs Category: Physiological Integrity
296. Which of the following are components of the Institute for Healthcare Improvement's
297. (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 ANS: A, B, C, D
298. Options A, B, C, and D are components of the IHI ventilator bundle. Oral care with
299. chlorhexidine has recently been added to the IHI bundle. Swabbing alone provides comfort
300. care.
301. DIF: Cognitive Level: Apply/Application REF: p. 407
302. OBJ: Formulate a plan of care for the patient with ARF.
303. TOP: Nursing Process Step: Implementation
304. MSC: NCLEX Client Needs Category: Physiological Integrity
305. Select the strategies for preventing deep vein thrombosis (DVT) and pulmonary embolus
306. (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 ANS: A, B, C
307. Graduated compression stockings, sequential compression devices, and anticoagulation can
308. reduce the risk for DVT. Physical activity can also reduce the risk; bed rest increases the
309. risk. Leg massage is not recommended.
310. DIF: Cognitive Level: Understand/Comprehension REF: Box 15-
311. OBJ: Formulate a plan of care for the patient with ARF.
312. TOP: Nursing Process Step: Assessment
313. MSC: NCLEX Client Needs Category: Physiological Integrity
314. The nurse is caring for a mechanically ventilated patient. The nurse understands that
315. strategies to prevent ventilator-associated pneumonia include which of the following?

316. (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 ANS: A, B, D
317. Condensate should be drained away from the patient to avoid drainage back into the
318. patient's airway. Prevention guidelines recommend elevating the head of bed at 30 to 45
319. degrees. Regular antiseptic oral care, with an agent such as chlorhexidine, reduces
320. oropharyngeal colonization. Daily "sedation holidays" help determine the need to continue
321. mechanical ventilation. Normal saline is not recommended as part of the suctioning
322. procedure, and it may increase the risk for infection.
323. DIF: Cognitive Level: Understand/Comprehension REF: Box 15-
324. OBJ: Formulate a plan of care for the patient with ARF.
325. TOP: Nursing Process Step: Implementation
326. MSC: NCLEX Client Needs Category: Physiological Integrity
327. The nurse is caring for a patient in acute respiratory failure and understands that the patient
328. should be positioned (Select all that apply.) a. high Fowler's. b. side lying with head of bed elevated. c. sitting in a chair. d. supine with the bed flat. e. Trendelenburg. - Correct answer ANS: A, B, C
329. Patients in respiratory distress are unable to tolerate a flat position. Trendelenburg would
330. also be contraindicated as the weight of the organs on the lungs would inhibit movement.
331. High Fowler's is appropriate. Side lying with head of bed elevated, sitting in a chair, and
332. high Fowler's position are all appropriate ways to position the patient to facilitate gas
333. exchange and comfort.
334. DIF: Cognitive Level: Understand/Comprehension REF: p. 393
335. OBJ: Formulate a plan of care for the patient with ARF.
336. TOP: Nursing Process Step: Implementation
337. MSC: NCLEX Client Needs Category: Physiological Integrity

338. The nurse is caring for a patient with cystic fibrosis (CF) and understands that treatment
339. consists of which of the following? (Select all that apply.) a. Airway clearance therapies b. Antibiotic therapy c. Nutritional support d. Tracheostomy e. Lung transplant - Correct answer ANS: A, B, C, E
340. The three cornerstones of care for a patient with CF are antibiotic therapy, airway clearance,
341. and nutritional support. Lung transplant is a treatment modality for those who can get a
342. match and who do not have current respiratory failure. A tracheostomy is not a standard
343. treatment for CF.
344. DIF: Cognitive Level: Apply/Application REF: pp. 413-
345. OBJ: Discuss medical management of the patient with ARF.
346. TOP: Nursing Process Step: Implementation
347. MSC: NCLEX Client Needs Category: Physiological Integrity
348. When fluid is present in the alveoli, a. alveoli collapse, and atelectasis occurs. b. diffusion of oxygen and carbon dioxide is impaired. c. hypoventilation occurs. d. the patient is in heart failure. - Correct answer ANS: B
349. Fluid prevents the diffusion of gases. It does not cause atelectasis or hypoventilation. Fluid
350. can be present in the alveoli secondary to heart failure; however, there are other causes as
351. well, such as acute respiratory distress syndrome.
352. DIF: Cognitive Level: Understand/Comprehension REF: p. 391
353. OBJ: Describe the pathophysiology of ARF.
354. TOP: Nursing Process Step: Assessment
355. MSC: NCLEX Client Needs Category: Physiological Integrity