Chapter 68- Respiratory Failure and Acute Respiratory Distress Syndrome Med Surg Questions

Question 1

When explaining respiratory failure to the patient’s family, what should the nurse use as an accurate description?

a. The absence of ventilation
b. Any episode in which part of the airway is obstructed
c. Inadequate gas exchange to meet the metabolic needs of the body
d. An episode of acute hypoxemia caused by a pulmonary dysfunction

Answer 1

c. Respiratory failure results when the transfer of oxygen
or carbon dioxide function of the respiratory system is impaired and, although the definition is determined by PaO2 and PaCO2 levels, the major factor in respiratory failure is inadequate gas exchange to meet tissue oxygen (O2) needs. Absence of ventilation is respiratory arrest and partial airway obstruction may not necessarily cause respiratory failure. Acute hypoxemia may be caused by factors other than pulmonary dysfunction.

Question 2

Which descriptions are characteristic of hypoxemic respiratory failure (select all that apply)?

a. Referred to as ventilatory failure
b. Primary problem is inadequate O2 transfer
c. Risk of inadequate O2 saturation of hemoglobin exists
d. Body is unable to compensate for acidemia of increased PaCO2
e. Most often caused by ventilation-perfusion (V/Q) mismatch and shunt
f. Exists when PaO2 is 60 mm Hg or less, even when O2 is administered at 60%

Answer 2

b, c, e, f. Hypoxemic respiratory failure is often caused
by ventilation-perfusion (V/Q) mismatch and shunt. It is called oxygenation failure because the primary problem is inadequate oxygen transfer. There is a risk of inadequate oxygen saturation of hemoglobin and it exists when PaO2 is 60 mm Hg or less, even when oxygen is administered at 60%. Ventilatory failure is hypercapnic respiratory failure. Hypercapnic respiratory failure results from an imbalance between ventilatory supply and ventilatory demand and the body is unable to compensate for the acidemia of increased PaCO2.

Question 3

When teaching the patient about what was happening when experiencing an intrapulmonary shunt, which
explanation is accurate?
a. This occurs when an obstruction impairs the flow of blood to the ventilated areas of the lung.
b. This occurs when blood passes through an anatomic channel in the heart and bypasses the lungs.
c. This occurs when blood flows through the capillaries in the lungs without participating in gas exchange.
d. Gas exchange across the alveolar capillary interface is compromised by thickened or damaged alveolar
membranes.

Answer 3

c. Intrapulmonary shunt occurs when blood flows through the capillaries in the lungs without participating in gas exchange (e.g., acute respiratory distress syndrome [ARDS], pneumonia). Obstruction impairs the flow of blood to the ventilated areas of the lung in a V/Q mismatch ratio greater than 1 (e.g., pulmonary embolus). Blood passes through an anatomic channel in the heart and bypasses the lungs with anatomic shunt (e.g., ventricular septal defect). Gas exchange across the alveolar capillary interface is compromised by thickened or damaged alveolar membranes
in diffusion limitation (e.g., pulmonary fibrosis, ARDS).

Question 4

When the V/Q lung scan result returns with a mismatch ratio that is greater than 1, which condition should be suspected?

a. Pain
b. Atelectasis
c. Pulmonary embolus
d. Ventricular septal defect

Answer 4

c. There will be more ventilation than perfusion (V/Q
ratio greater than 1) with a pulmonary embolus. Pain and atelectasis will cause a V/Q ratio less than 1. A ventricular septal defect causes an anatomic shunt as the blood bypasses the lungs.

Question 5

Which physiologic mechanism of hypoxemia occurs with pulmonary fibrosis?

a. Anatomic shunt
b. Diffusion limitation
c. Intrapulmonary shunt
d. V/Q mismatch ratio of less than 1

Answer 5

b. Diffusion limitation in pulmonary fibrosis is caused by thickened alveolar-capillary interface, which slows gas transport.

Question 6

Which patient with the following manifestations is most likely to develop hypercapnic respiratory failure?

a. Rapid, deep respirations in response to pneumonia
b. Slow, shallow respirations as a result of sedative overdose
c. Large airway resistance as a result of severe bronchospasm
d. Poorly ventilated areas of the lung caused by pulmonary edema

Answer 6

b. Hypercapnic respiratory failure is associated with alveolar hypoventilation with increases in alveolar and arterial carbon dioxide (CO2) and often is caused by problems outside the lungs. A patient with slow, shallow respirations is not exchanging enough gas volume to eliminate CO2. Deep, rapid respirations reflect hyperventilation and often accompany lung problems that cause hypoxemic respiratory failure. Pulmonary edema and large airway resistance cause obstruction of oxygenation and result in a V/Q mismatch or shunt typical of hypoxemic respiratory failure.

Question 7

Which arterial blood gas (ABG) results would most likely indicate acute respiratory failure in a patient with chronic
lung disease?
a. PaO2 52 mm Hg, PaCO2 56 mm Hg, pH 7.4
b. PaO2 46 mm Hg, PaCO2 52 mm Hg, pH 7.36
c. PaO2 48 mm Hg, PaCO2 54 mm Hg, pH 7.38
d. PaO2 50 mm Hg, PaCO2 54 mm Hg, pH 7.28

Answer 7

d. In a patient with normal lung function, respiratory failure is commonly defined as a PaO2 ≤60 mm Hg or a PaCO2 >45 mm Hg or both. However, because the patient with chronic pulmonary disease normally maintains low PaO2 and high PaCO2, acute respiratory failure in these patients can be defined as an acute decrease in PaO2 or an increase in PaCO2 from the patient’s baseline parameters, accompanied by an acidic pH. The pH of 7.28 reflects an acidemia and a loss of compensation in the patient with chronic lung disease.

Question 8

The patient is being admitted to the intensive care unit (ICU) with hypercapnic respiratory failure. Which
manifestations should the nurse expect to assess in the patient (select all that apply)?
a. Cyanosis d. Respiratory acidosis
b. Metabolic acidosis e. Use of tripod position
c. Morning headache f. Rapid, shallow respirations

Answer 8

c, d, e, f. Morning headache, respiratory acidosis, the use of tripod position, and rapid, shallow respirations would be expected. The other manifestations are characteristic of hypoxemic respiratory failure.

Question 9

Which assessment finding should cause the nurse to suspect the early onset of hypoxemia?

a. Restlessness c. Central cyanosis
b. Hypotension d. Cardiac dysrhythmias

Answer 9

a. Because the brain is very sensitive to a decrease in oxygen delivery, restlessness, agitation, disorientation, and confusion are early signs of hypoxemia, for which the nurse should be alert. Mild hypertension is also an early sign, accompanied by tachycardia. Central cyanosis is an unreliable, late sign of hypoxemia. Cardiac dysrhythmias also occur later.

Question 10

Which changes of aging contribute to the increased risk for respiratory failure in older adults (select all that apply)?

a. Alveolar dilation
b. Increased delirium
c. Changes in vital signs
d. Increased infection risk
e. Decreased respiratory muscle strength
f. Diminished elastic recoil within the airways

Answer 10

a, d, e, f. Changes from aging that increase the older
adult’s risk for respiratory failure include alveolar dilation, increased risk for infection, decreased respiratory muscle strength, and diminished elastic recoil in the airways. Although delirium can complicate ventilator management, it does not increase the older patient’s risk for respiratory failure. The older adult’s blood pressure (BP) and heart rate (HR) increase but this does not affect the risk for respiratory failure. The ventilatory capacity is decreased and the larger air spaces decrease the surface area for gas exchange, which increases the risk.

Question 11

The nurse assesses that a patient in respiratory distress is developing respiratory fatigue and the risk of respiratory
arrest when the patient displays which behavior?
a. Cannot breathe unless he is sitting upright
b. Uses the abdominal muscles during expiration
c. Has an increased inspiratory-expiratory (I/E) ratio
d. Has a change in respiratory rate from rapid to slow

Answer 11

d. The increase in respiratory rate required to blow off accumulated CO2 predisposes to respiratory muscle fatigue. The slowing of a rapid rate in a patient in acute distress indicates tiring and the possibility of respiratory arrest unless ventilatory assistance is provided. A decreased inspiratory-expiratory (I/E) ratio, orthopnea, and accessory muscle use are common findings in respiratory distress but do not necessarily signal respiratory fatigue or arrest.

Question 12

A patient has a PaO2 of 50 mm Hg and a PaCO2 of 42 mm Hg because of an intrapulmonary shunt. Which therapy is
the patient most likely to respond best to?
a. Positive pressure ventilation
b. Oxygen administration at a FIO2 of 100%
c. Administration of O2 per nasal cannula at 1 to 3 L/min
d. Clearance of airway secretions with coughing and suctioning

Answer 12

a. Patients with a shunt are usually more hypoxemic than patients with a V/Q mismatch because the alveoli are filled with fluid, which prevents gas exchange. Hypoxemia resulting from an intrapulmonary shunt is usually not responsive to high O2 concentrations and the patient will usually require positive pressure ventilation. Hypoxemia associated with a V/Q mismatch usually responds favorably to O2 administration at 1 to 3 L/min by nasal cannula. Removal of secretions with coughing and suctioning is generally not effective in reversing an acute hypoxemia resulting from a shunt.

Question 13

A patient with a massive hemothorax and pneumothorax has absent breath sounds in the right lung. To promote
improved V/Q matching, how should the nurse position the patient?
a. On the left side
b. On the right side
c. In a reclining chair bed
d. Supine with the head of the bed elevated

Answer 13

a. When there is impaired function of one lung, the patient should be positioned with the unaffected lung in the dependent position to promote perfusion to the functioning tissue. If the diseased lung is positioned dependently, more V/Q mismatch would occur. The head of the bed may be elevated or a reclining chair may be used, with the patient positioned on the unaffected side, to maximize thoracic expansion if the patient has increased work of breathing.

Question 14

A patient in hypercapnic respiratory failure has a nursing diagnosis of ineffective airway clearance related to
increasing exhaustion. What is an appropriate nursing intervention for this patient?
a. Inserting an oral airway
b. Performing augmented coughing
c. Teaching the patient huff coughingd. Teaching the patient slow pursed lip breathing

Answer 14

b. Augmented coughing is done by applying pressure on the abdominal muscles at the beginning of expiration. This type of coughing helps to increase abdominal pressure and expiratory flow to assist the cough to remove secretions in the patient who is exhausted. An oral airway is used only if there is a possibility that the tongue will obstruct the airway. Huff coughing prevents the glottis from closing during the cough and works well for patients with chronic obstructive pulmonary disease (COPD) to clear central airways. Slow pursed lip breathing allows more time for expiration and prevents small bronchioles from collapsing.

Question 15

The patient with a history of heart failure and acute respiratory failure has thick secretions that she is having
difficulty coughing up. Which intervention would best help to mobilize her secretions?
a. Administer more IV fluid
b. Perform postural drainage
c. Provide O2 by aerosol mask
d. Suction airways nasopharyngeally

Answer 15

c. For the patient with a history of heart failure, current acute respiratory failure, and thick secretions, the best intervention is to liquefy the secretions with either aerosol mask or using normal saline administered by a nebulizer. Excess IV fluid may cause cardiovascular distress and the patient probably would not tolerate postural drainage with her history. Suctioning thick secretions without thinning them is difficult and increases the patient’s difficulty in maintaining oxygenation. With copious secretions, this could be done after thinning the secretions.

Question 16

Priority Decision: After endotracheal intubation and mechanical ventilation have been started, a patient in
respiratory failure becomes very agitated and is breathing asynchronously with the ventilator. What is it most
important for the nurse to do first?
a. Evaluate the patient’s pain level, ABGs, and electrolyte values
b. Sedate the patient to unconsciousness to eliminate patient awareness
c. Administer the PRN vecuronium (Norcuron) to promote synchronous ventilations
d. Slow the rate of ventilations provided by the ventilator to allow for spontaneous breathing by the patient

Answer 16

a. It is most important to assess the patient for the cause of the restlessness and agitation (e.g., pain, hypoxemia, electrolyte imbalances) and treat the underlying cause before sedating the patient. Although sedation, analgesia, and neuromuscular blockade are often used to control agitation and pain, these treatments may contribute to prolonged ventilator support and hospital days.

Question 17

What is the primary reason that hemodynamic monitoring is instituted in severe respiratory failure?

a. To detect V/Q mismatches
b. To continuously measure the arterial BP
c. To evaluate oxygenation and ventilation status
d. To evaluate cardiac status and blood flow to tissues

Answer 17

d. Hemodynamic monitoring with a pulmonary artery catheter is instituted in severe respiratory failure to determine the amount of blood flow to tissues and the response of the lungs and heart to hypoxemia. Continuous BP monitoring may be performed but BP is a reflection of cardiac activity, which can be determined by the pulmonary artery catheter findings. Arterial blood gases (ABGs) are important to evaluate oxygenation and ventilation status and V/Q mismatches.

Question 18

Patients with acute respiratory failure will have drug therapy to meet their individual needs. Which drugs will meet
the goal of reducing pulmonary congestion (select all that apply)?
a. Morphine d. Albuterol (Ventolin)
b. Furosemide (Lasix) e. Ceftriaxone (Rocephin)
c. Nitroglycerin (Tridil) f. Methylprednisolone (Solu-
Medrol)

Answer 18

a, b, c. Morphine and nitroglycerin (e.g., Tridil) will decrease pulmonary congestion caused by heart failure; IV diuretics (e.g., furosemide [Lasix]) are also used. Inhaled albuterol (Ventolin) or metaproterenol (Alupent) will relieve bronchospasms. Ceftriaxone (Rocephin) and azithromycin (Zithromax) are used to treat pulmonary infections. Methylprednisolone (Solu-Medrol), an IV corticosteroid, will reduce airway inflammation. Morphine is also used to decrease anxiety, agitation, and pain.

Question 19

In caring for a patient in acute respiratory failure, the nurse recognizes that noninvasive positive pressure ventilation
(NIPPV) may be indicated for which patient?
a. Is comatose and has high oxygen requirements
b. Has copious secretions that require frequent suctioning
c. Responds to hourly bronchodilator nebulization treatments
d. Is alert and cooperative but has increasing respiratory exhaustion

Answer 19

d. Noninvasive positive pressure ventilation (NIPPV)
involves the application of a face mask and delivery of
a volume of air under inspiratory pressure. Because the device is worn externally, the patient must be able to cooperate in its use and frequent access to the airway for suctioning or inhaled medications must not be necessary. It is not indicated when high levels of oxygen are needed or respirations are absent.

Question 20

The patient progressed from acute lung injury to acute respiratory distress syndrome (ARDS). He is on the ventilator and receiving propofol (Diprivan) for sedation and fentanyl (Sublimaze) to decrease anxiety, agitation, and pain in order to decrease his work of breathing, O2 consumption, carbon dioxide production, and risk of injury. What intervention is recommended in caring for this patient?

a. A sedation holiday
b. Monitoring for hypermetabolism
c. Keeping his legs still to avoid dislodging the airway
d. Repositioning him every 4 hours to decrease agitation

Answer 20

a. A sedation holiday is needed to assess the patient’s condition and readiness to extubate. A hypermetabolic state occurs with critical illness. With malnourished patients, enteral or parenteral nutrition is started within 24 hours; with well-nourished patients it is started within 3 days. With these medications, the patient will be assessed for cardiopulmonary depression. Venous thromboembolism prophylaxis will be used but there is no reason to keep the legs still. Repositioning the patient every 2 hours may help to decrease discomfort and agitation.

Question 21

Although ARDS may result from direct lung injury or indirect lung injury as a result of systemic inflammatory response syndrome (SIRS), the nurse is aware that ARDS is most likely to occur in the patient with a host insult resulting from

a. sepsis.
b. oxygen toxicity.
c. prolonged hypotension.
d. cardiopulmonary bypass.

Answer 21

a. Although ARDS may occur in the patient who has virtually any severe illness and may be both a cause and a result of systemic inflammatory response syndrome (SIRS), the most common precipitating insults of ARDS are sepsis, gastric aspiration, and severe massive trauma.

Question 22

What are the primary pathophysiologic changes that occur in the injury or exudative phase of ARDS (select all
that apply)?
a. Atelectasis
b. Shortness of breath
c. Interstitial and alveolar edema
d. Hyaline membranes line the alveolie.
e. Influx of neutrophils, monocytes, and lymphocytes

Answer 22

a, c, d. The injury or exudative phase is the early phase of ARDS when atelectasis and interstitial and alveoli edema occur and hyaline membranes composed of necrotic cells, protein, and fibrin line the alveoli. Together, these decrease gas exchange capability and lung compliance. Shortness
of breath occurs but it is not a physiologic change. The increased inflammation and proliferation of fibroblasts occurs in the reparative or proliferative phase of ARDS, which occurs 1 to 2 weeks after the initial lung injury.

Question 23

In patients with ARDS who survive the acute phase of lung injury, what manifestations are seen when they progress
to the fibrotic phase?
a. Chronic pulmonary edema and atelectasis
b. Resolution of edema and healing of lung tissue
c. Continued hypoxemia because of diffusion limitation
d. Increased lung compliance caused by the breakdown of fibrotic tissue

Answer 23

c. In the fibrotic phase of ARDS, diffuse scarring and fibrosis of the lungs occur, resulting in decreased surface area for gas exchange and continued hypoxemia caused by diffusion limitation. Although edema is resolved, lung compliance is decreased because of interstitial fibrosis. Long-term mechanical ventilation is required. The patient has a poor prognosis for survival.

Question 24

In caring for the patient with ARDS, what is the most characteristic sign the nurse would expect the patient to exhibit?

a. Refractory hypoxemia
b. Bronchial breath sounds
c. Progressive hypercapnia
d. Increased pulmonary artery wedge pressure (PAWP)

Answer 24

a. Refractory hypoxemia, hypoxemia that does not respond to increasing concentrations of oxygenation by any route, is a hallmark of ARDS and is always present. Bronchial breath sounds may be associated with the progression of ARDS. PaCO2 levels may be normal until the patient is no longer able to compensate in response to the hypoxemia. Pulmonary artery wedge pressure (PAWP) that is normally elevated in cardiogenic pulmonary edema is normal in the pulmonary edema of ARDS.

Question 25

The nurse suspects the early stage of ARDS in any seriously ill patient who manifests what?

a. Develops respiratory acidosis
b. Has diffuse crackles and rhonchi
c. Exhibits dyspnea and restlessness
d. Has a decreased PaO2 and an increased PaCO2

Answer 25

c. Early signs of ARDS are insidious and difficult to detect but the nurse should be alert for any early signs
of hypoxemia, such as dyspnea, restlessness, tachypnea, cough, and decreased mentation, in patients at risk for ARDS. Abnormal findings on physical examination or diagnostic studies, such as adventitious lung sounds, signs of respiratory distress, respiratory alkalosis, or decreasing PaO2, are usually indications that ARDS has progressed beyond the initial stages.

Question 26

A patient with ARDS has a nursing diagnosis of risk for infection. To detect the presence of infections commonly
associated with ARDS, what should the nurse monitor?
a. Gastric aspirate for pH and blood c. Subcutaneous emphysema of the face, neck, and chest
b. Quality, quantity, and consistency of sputum d. Mucous membranes of the oral cavity for open lesions

Answer 26

b. Ventilator-associated pneumonia (VAP) is one of the most common complications of ARDS. Early detection requires frequent monitoring of sputum smears and cultures and assessment of the quality, quantity, and consistency of sputum. Prevention of VAP is done with strict infection control measures, ventilator bundle protocol, and subglottal secretion drainage. Blood in gastric aspirate may indicate a stress ulcer and subcutaneous emphysema of the face, neck, and chest occurs with barotrauma during mechanical ventilation. Oral infections may result from prophylactic antibiotics and impaired host defenses but are not common.

Question 27

The best patient response to treatment of ARDS occurs when initial management includes what?

a. Treatment of the underlying condition
b. Administration of prophylactic antibiotics
c. Treatment with diuretics and mild fluid restrictiond. Endotracheal intubation and mechanical ventilation

Answer 27

a. Because ARDS is precipitated by a physiologic insult, a critical factor in its prevention and early management is treatment of the underlying condition. Prophylactic antibiotics, treatment with diuretics and fluid restriction, and mechanical ventilation are also used as ARDS progresses.

Question 28

When mechanical ventilation is used for the patient with ARDS, what is the rationale for applying positive endexpiratory
pressure (PEEP)?
a. Prevent alveolar collapse and open up collapsed alveoli
b. Permit smaller tidal volumes with permissive hypercapnia
c. Promote complete emptying of the lungs during exhalation
d. Permit extracorporeal oxygenation and carbon dioxide removal outside the body

Answer 28

a. Positive end-expiratory pressure (PEEP) used with mechanical ventilation applies positive pressure to the airway and lungs at the end of exhalation, keeping the lung partially expanded and preventing collapse of the alveoli and helping to open up collapsed alveoli. Permissive hypercapnia is allowed when the patient with ARDS is ventilated with smaller tidal volumes to prevent barotrauma. Extracorporeal membrane oxygenation and extracorporeal CO2 removal involve passing blood across a gas-exchanging membrane outside the body and then returning oxygenated blood to the body.

Question 29

The nurse suspects that a patient with PEEP is experiencing negative effects of this ventilatory maneuver when
which of the following is assessed?
a. Increasing PaO2
b. Decreasing blood pressure
c. Decreasing heart rate (HR)
d. Increasing central venous pressure (CVP)

Answer 29

b. PEEP increases intrathoracic and intrapulmonic pressures, compresses the pulmonary capillary bed, and reduces blood return to both the right and left sides of the heart. Increased PaO2 is an expected effect of PEEP. Preload (CVP) and cardiac output (CO) are decreased, often with a dramatic decrease in BP.

Question 30

Prone positioning is considered for a patient with ARDS who has not responded to other measures to increase PaO2.
The nurse knows that this strategy will
a. increase the mobilization of pulmonary secretions.
b. decrease the workload of the diaphragm and intercostal muscles.
c. promote opening of atelectatic alveoli in the upper portion of the lung.
d. promote perfusion of nonatelectatic alveoli in the anterior portion of the lung.

Answer 30

d. When a patient with ARDS is supine, alveoli in the posterior areas of the lung are dependent and fluid-filled and the heart and mediastinal contents place more pressure on the lungs, predisposing to atelectasis. If the patient is turned prone, air-filled nonatelectatic alveoli in the anterior portion of the lung receive more blood and perfusion may be better matched to ventilation, causing less V/Q mismatch. Lateral rotation therapy is used to stimulate postural drainage and help mobilize pulmonary secretions.