Chapter 68- Respiratory Failure and Acute Respiratory Distress Syndrome

Question 1

After receiving change-of-shift report on a medical unit, which patient should the nurse
assess first?
a. A patient with cystic fibrosis who has thick, green-colored sputum
b. A patient with pneumonia who has crackles bilaterally in the lung bases
c. A patient with emphysema who has an oxygen saturation of 90% to 92%
d. A patient with septicemia who has intercostal and suprasternal retractions

Answer 1

ANS: D
This patient’s history of septicemia and labored breathing suggest the onset
of ARDS, which will require rapid interventions such as administration of
oxygen and use of positive pressure ventilation. The other patients should
also be assessed as quickly as possible, but their assessment data are typical
of their disease processes and do not suggest deterioration in their status

Question 2

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.
d. Notify the health care provider about the patient’s status

Answer 2

ANS: C
Agitation may be an early indicator of hypoxemia.
The other actions may also be appropriate,
depending on the findings about oxygen saturation

Question 3

The nurse documents the vital signs for a patient admitted 2 days ago with gram-negative sepsis:
temperature 101.2° F, blood pressure 90/56 mm Hg, pulse 92, respirations 34. Which action should the
nurse take next?
a. Give the scheduled IV antibiotic.
b. Give the PRN acetaminophen (Tylenol).
c. Obtain oxygen saturation using pulse oximetry.
d. Notify the health care provider of the patient’s vital signs.

Answer 3

ANS: C
The patient’s increased respiratory rate in combination with the admission diagnosis of gramnegative
sepsis indicates that acute respiratory distress syndrome (ARDS) may be developing.
The nurse should check for hypoxemia, a hallmark of ARDS. The health care provider should
be notified after further assessment of the patient. Giving the scheduled antibiotic and the
PRN acetaminophen will also be done, but they are not the highest priority for a patient who
may be developing ARDS

Question 4

The nurse is caring for a 33-year-old 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/minute.

Answer 4

ANS: A
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

Question 5

The nurse is caring for a 78-year-old patient who was hospitalized 2 days earlier with communityacquired
pneumonia. Which assessment information is most important to communicate to the health care
provider?
a. Scattered crackles bilaterally in the posterior lung bases.
b. Persistent cough that is productive of blood-tinged sputum.
c. Temperature of 101.5° F (38.6° C) after 2 days of IV antibiotic therapy.
d. Decreased oxygen saturation to 90% with 100% O2 by non-rebreather mask.

Answer 5

ANS: D
The patient’s low SpO2 despite receiving a high fraction of inspired oxygen (FIO2) indicates
the possibility of acute respiratory distress syndrome (ARDS). The patient’s blood-tinged
sputum and scattered crackles are not unusual in a patient with pneumonia, although they do
require continued monitoring. The continued temperature elevation indicates a possible need
to change antibiotics, but this is not as urgent a concern as the progression toward hypoxemia
despite an increase in O2 flow rate

Question 6

A nurse is caring for an obese patient with right lower lobe pneumonia. Which position will be
best to improve gas exchange?
a. On the left side
b. On the right side
c. In the tripod position
d. In the high-Fowler's position

Answer 6

ANS: A
The patient should be positioned with the “good” lung in the
dependent position to improve the match between ventilation
and perfusion. The obese patient’s abdomen will limit respiratory
excursion when sitting in the high-Fowler’s or tripod positions

Question 7

The nurse is caring for a patient who is intubated and receiving positive pressure ventilation to treat acute
respiratory distress syndrome (ARDS). Which finding is most important to report to the health care
provider?
a. Blood urea nitrogen (BUN) level 32 mg/dL
b. Red-brown drainage from orogastric tube
c. Scattered coarse crackles heard throughout lungs
d. Arterial blood gases: pH 7.31, PaCO2 50, PaO2 68

Answer 7

ANS: B
The nasogastric drainage indicates possible gastrointestinal bleeding and/or stress ulcer, and
should be reported. The pH and PaCO2 are slightly abnormal, but current guidelines
advocating for permissive hypercapnia indicate that these would not indicate an immediate
need for a change in therapy. The BUN is slightly elevated but does not indicate an immediate
need for action. Adventitious breath sounds are commonly heard in patients with ARDS

Question 8

A nurse is caring for a patient who is orally intubated and receiving mechanical ventilation. To decrease
the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care?
a. Elevate head of bed to 30 to 45 degrees.
b. Suction the endotracheal tube every 2 to 4 hours.
c. Limit the use of positive end-expiratory pressure.
d. Give enteral feedings at no more than 10 mL/hr.

Answer 8

ANS: A
Elevation of the head decreases the risk for aspiration. Positive endexpiratory
pressure is frequently needed to improve oxygenation in patients
receiving mechanical ventilation. Suctioning should be done only when the
patient assessment indicates that it is necessary. Enteral feedings should
provide adequate calories for the patient’s high energy needs

Question 9

A nurse is caring for a patient with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation
using synchronized intermittent mandatory ventilation (SIMV). The settings include fraction of inspired oxygen (FIO2)
80%, tidal volume 450, rate 16/minute, and positive end-expiratory pressure (PEEP) 5 cm. Which assessment finding is
most important for the nurse to report to the health care provider?
a. Oxygen saturation 99%
b. Respiratory rate 22 breaths/minute
c. Crackles audible at lung bases
d. Heart rate 106 beats/minute

Answer 9

ANS: A
The FIO2 of 80% increases the risk for oxygen toxicity. Because the patient’s
O2 saturation is 99%, a decrease in FIO2 is indicated to avoid toxicity. The
other patient data would be typical for a patient with ARDS and would not
need to be urgently reported to the health care provider

Question 10

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.

Answer 10

ANS: B
The subcutaneous emphysema indicates barotrauma caused by positive
pressure ventilation and PEEP. Bradycardia, hypoxemia, and bronchial breath
sounds are all concerns and will need to be addressed, but they are not
specific indications that PEEP should be reduced

Question 11

The oxygen saturation (SpO2) for a patient with left lower lobe pneumonia is 90%. The patient has
rhonchi, a weak cough effort, and complains of fatigue. Which action is a priority for the nurse to take?
a. Position the patient on the left side.
b. Assist the patient with staged coughing.
c. Place a humidifier in the patient’s room.
d. Schedule a 2-hour rest period for the patient.

Answer 11

ANS: B
The patient’s assessment indicates that assisted coughing is needed to help remove
secretions, which will improve oxygenation. A 2-hour rest period at this time may allow the
oxygen saturation to drop further. Humidification will not be helpful unless the secretions can
be mobilized. Positioning on the left side may cause a further decrease in oxygen saturation
because perfusion will be directed more toward the more poorly ventilated lung

Question 12

A patient admitted with acute respiratory failure has a nursing diagnosis of ineffective airway clearance
related to thick, secretions. Which action is a priority for the nurse to include in the plan of care?
a. Encourage use of the incentive spirometer.
b. Offer the patient fluids at frequent intervals.
c. Teach the patient the importance of ambulation.
d. Titrate oxygen level to keep O2 saturation >93%.

Answer 12

ANS: B
Because the reason for the poor airway clearance is the thick secretions, the best action will
be to encourage the patient to improve oral fluid intake. Patients should be instructed to use
the incentive spirometer on a regular basis (e.g., every hour) in order to facilitate the clearance
of the secretions. The other actions may also be helpful in improving the patient’s gas
exchange, but they do not address the thick secretions that are causing the poor airway
clearance

Question 13

A patient develops increasing dyspnea and hypoxemia 2 days after heart surgery. To determine whether
the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by heart failure,
the nurse will plan to assist with
a. obtaining a ventilation-perfusion scan.
b. drawing blood for arterial blood gases.
c. insertion of a pulmonary artery catheter.
d. positioning the patient for a chest x-ray.

Answer 13

ANS: C
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

Question 14

A patient with acute respiratory distress syndrome (ARDS) and acute kidney injury has the following
medications ordered. Which medication should the nurse discuss with the health care provider before
giving?
a. Pantoprazole (Protonix) 40 mg IV
b. Gentamicin (Garamycin) 60 mg IV
c. Sucralfate (Carafate) 1 g per nasogastric tube
d. Methylprednisolone (Solu-Medrol) 60 mg IV

Answer 14

ANS: 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

Question 15

A patient with acute respiratory distress syndrome (ARDS) is placed in the prone position. When prone
positioning is used, 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.

Answer 15

ANS: A
The purpose of prone positioning is to improve the patient’s
oxygenation as indicated by the PaO2 and SaO2. The other
information will be collected but does not indicate whether
prone positioning has been effective

Question 16

A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical
ventilation develops a right pneumothorax. Which action will the nurse anticipate taking next?
a. Increase the tidal volume and respiratory rate.
b. Increase the fraction of inspired oxygen (FIO2).
c. Perform endotracheal suctioning more frequently.
d. Lower the positive end-expiratory pressure (PEEP).

Answer 16

ANS: D
Because barotrauma is associated with high airway pressures, the
level of PEEP should be decreased. The other actions will not
decrease the risk for pneumothorax

Question 17

A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department
complaining of shortness of breath and dyspnea 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 respirations have decreased from 30 to 10 breaths/minute.
d. The patient’s pulse oximetry indicates an O2 saturation of 91%.

Answer 17

ANS: D
A decrease in respiratory rate in a patient with respiratory distress suggests the onset of
fatigue and a high risk for respiratory arrest. Therefore immediate action such as positive
pressure ventilation is needed. Patients who are experiencing respiratory distress frequently sit
in the tripod position because it decreases the work of breathing. Crackles in the lung bases
may be the baseline for a patient with COPD. An oxygen saturation of 91% is common in
patients with COPD and will provide adequate gas exchange and tissue oxygenation

Question 18

A patient with respiratory failure has a respiratory rate of 6 breaths/minute and an oxygen saturation
(SpO2) of 88%. The patient is increasingly lethargic. Which intervention will the nurse anticipate?
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 continuous positive pressure ventilation (CPAP)

Answer 18

ANS: 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. CPAP requires that the patient initiate an adequate respiratory rate to allow
adequate gas exchange

Question 19

To evaluate the effectiveness of ordered interventions for a patient with ventilatory failure,
which diagnostic test will be most useful to the nurse?
a. Chest x-ray
b. Oxygen saturation
c. Arterial blood gas analysis
d. Central venous pressure monitoring

Answer 19

ANS: C
Arterial blood gas (ABG) analysis is most useful in this setting because
ventilatory failure causes problems with CO2 retention, and ABGs provide
information about the PaCO2 and pH. The other tests may also be done to
help in assessing oxygenation or determining the cause of the patient’s
ventilatory failure

Question 20

When admitting a patient with possible respiratory failure with a high PaCO2, which
assessment information should be immediately reported to the health care provider?
a. The patient is somnolent.
b. The patient complains of weakness.
c. The patient’s blood pressure is 164/98.
d. The patient’s oxygen saturation is 90%

Answer 20

ANS: 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.

Question 21

When assessing a patient with chronic obstructive pulmonary disease (COPD), the nurse finds
a new onset of agitation and confusion. Which action should the nurse take first?
a. Notify the health care provider.
b. Check pupils for reaction to light.
c. Attempt to calm and reorient the patient.
d. Assess oxygenation using pulse oximetry.

Answer 21

ANS: D
Because agitation and confusion are frequently the initial indicators of
hypoxemia, the nurse’s initial action should be to assess oxygen saturation.
The other actions are also appropriate, but assessment of oxygenation takes
priority over other assessments and notification of the health care provider

Question 22

Which actions should the nurse initiate 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. Elevate the head of the bed to at least 30°.
d. Give prescribed pantoprazole (Protonix).
e. Provide oral care with chlorhexidine (0.12%) solution daily

Answer 22

ANS: B, C, D, E
All of these interventions are part of the ventilator bundle that is
recommended to prevent VAP. Arterial blood gases may be
done daily but are not always necessary and do not help prevent
VAP

Question 23

Which information about a patient who is receiving cisatracurium (Nimbex) to prevent asynchronous
breathing with the positive pressure ventilator requires immediate action by the nurse?
a. Only continuous IV opioids have been ordered.
b. The patient does not respond to verbal stimulation.
c. There is no cough or gag when the patient is suctioned.
d. The patient’s oxygen saturation fluctuates between 90% to 93%.

Answer 23

ANS: A
Because neuromuscular blockade is extremely anxiety provoking, it is
essential that patients who are receiving neuromuscular blockade receive
concurrent sedation and analgesia. Absence of response to stimuli is
expected in patients receiving neuromuscular blockade. The oxygen
saturation is adequate

Question 24

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/LVN) 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.

Answer 24

ANS: D
Insertion of indwelling urinary catheters is included in LPN/LVN education and scope of
practice and can be safely delegated to an LPN/LVN who is experienced in caring for
critically ill patients. Placing a patient who is on a ventilator in the prone position requires
multiple staff, and should be supervised by an RN. Assessment of breath sounds and obtaining
central venous pressures require advanced assessment skills and should be done by the RN
caring for a critically ill patient

Question 25

Which statement by the nurse when explaining the purpose of positive end-expiratory
pressure (PEEP) to the family members of a patient with ARDS 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% oxygen to the lungs.”

Answer 25

ANS: B
By preventing alveolar collapse during expiration, PEEP improves gas
exchange and oxygenation. PEEP will not prevent lung damage (e.g., fibrotic
changes that occur with ARDS), push more air into the lungs, or change the
fraction of inspired oxygen (FIO2) delivered to the patient

Question 26

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 next?
a. Increase the oxygen flow rate.
b. Suction the patient’s oropharynx.
c. Instruct the patient to cough and deep breathe.
d. Help the patient to sit in a more upright position.

Answer 26

ANS: A
Increasing oxygen flow rate will usually improve oxygen saturation in
patients with ventilation-perfusion mismatch, as occurs with pulmonary
embolism. Because the problem is with perfusion, actions that improve
ventilation, such as deep breathing and coughing, sitting upright, and
suctioning, are not likely to improve oxygenation