Respiratory failure 4 nclex style questions PDF

Preview

Summary

Practice nclex style questions for skill and preparation for the nclex or chapter test...

Description

Chapter 68: Nursing Management: Respiratory Failure and Acute Respiratory Distress Syndrome Chapter 68: Nursing Management: Respiratory Failure and Acute Respiratory Distress Syndrome Test Bank MULTIPLE CHOICE 1. 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

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. DIF: Cognitive Level: Apply (application) REF: 1661 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 2. 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.

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. DIF: Cognitive Level: Apply (application) REF: 1656 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 3. 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)

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. DIF: Cognitive Level: Apply (application) REF: 1658 | 1662 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 4. 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.

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. DIF: Cognitive Level: Apply (application) REF: 1661-1662 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 5. A

nurse is caring for an obese patient with right lower lobe pneumonia. Which position will bebest 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

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. DIF: Cognitive Level: Apply (application) REF: 1662 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 6. 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%.

ANS: A

Increasing somnolence will decrease the patient’s respiratory rate and further increase the PaCO2and 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. DIF: Cognitive Level: Apply (application) REF: 1660

TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 7. 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

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. DIF: Cognitive Level: Apply (application) REF: 1669 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 8. 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.

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. DIF: Cognitive Level: Apply (application) REF: 1667 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

9. 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.

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. DIF: Cognitive Level: Apply (application) REF: 1668-1669 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 10. Which

statement by the nurse when explaining the purpose of positive endexpiratory 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.”

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. DIF: Cognitive Level: Understand (comprehension) REF: 1669 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 11. 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.

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. DIF: Cognitive Level: Apply (application) REF: 1670 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity 12. The nurse documents

the vital signs for a patient admitted 2 days ago with gramnegative 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.

ANS: C

The patient’s increased respiratory rate in combination with the admission diagnosis of gram-negative 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. DIF: Cognitive Level: Apply (application) REF: 1665 | 1667 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 13. 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.

ANS: A

Elevation of the head decreases the risk for aspiration. Positive end-expiratory 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. DIF: Cognitive Level: Apply (application) REF: 1668 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 14. 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%.

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. DIF: Cognitive Level: Apply (application) REF: 1662 OBJ: Special Questions: Prioritization TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 15. 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).

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. DIF: Cognitive Level: Apply (application) REF: 1668-1669 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity 16. After

receiving change-of-shift report on a medical unit, which patient should the nurse assessfirst? 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

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. DIF: Cognitive Level: Analyze (analysis) REF: 1659 | 1667 OBJ: Special Questions: Prioritization; Multiple Patients TOP: Nursing Process: Assessment MSC: NCLEX: Safe and Effective Care Environment 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%.

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. DIF: Cognitive Level: Apply (application) REF: 1659 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 18. 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.

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. DIF: Cognitive Level: Apply (application) REF: 1663 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity 19. 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.

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. DIF: Cognitive Level: Apply (application) REF: 1658 | 1665 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity 20. The nurse is

caring for a 78-year-old patient who was hospitalized 2 days earlier with community-acquired pneumonia. Which assessment information is most important to communicate to the health care provider? a.

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.

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 continue...