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Chapter 70: Nursing Management: Respiratory Failure and Acute RespiratoryDistress Syndrome
Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition
MULTIPLE CHOICE
1. To evaluate the effectiveness of prescribed therapies for a client with ventilatory failure,
which of the following diagnostic tests will be most useful to the nurse?
a. Chest x-rays
b. Pulse oximetry
c. Arterial blood gas (ABG) analysis
d. Pulmonary artery pressure monitoring
ANS: C
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 also may be done to help in assessing oxygenation or determining the cause of the
client’s ventilatory failure.
DIF: Cognitive Level: Application TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
2. The nurse is caring for a client who has been admitted with a pulmonary embolism and
notes a change in the client’s oxygen saturation (SpO2) from 94% to 88%. Which of the
following actions should the nurse implement?
a. Increase the oxygen flow rate.
b. Suction the client’s oropharynx.
c. Assist the client to cough and deep breathe.
d. Help the client to sit in a more upright position.
ANS: A
Increasing oxygen flow rate usually will improve oxygen saturation in clients 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: Application TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
3. The nurse is caring for a client with respiratory failure who has a respiratory rate of 8/min
and a SpO2 of 89%. The client is increasingly lethargic. Which of the following actions
should 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 bilevel positive pressure ventilation (BiPAP)
ANS: B
, The client’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 client’s respiratory rate is so low. Insertion of a
mini-tracheostomy will facilitate removal of secretions, but it will not improve the client’s
respiratory rate or oxygenation. BiPAP requires that the client initiate an adequate
respiratory rate to allow adequate gas exchange.
DIF: Cognitive Level: Application TOP: Nursing Process: Planning
MSC: NCLEX: Physiological Integrity
4. The pulse oximetry for a client with right lower lobe pneumonia indicates an oxygen
saturation of 90%. The client has rhonchi, a weak cough effort, and complains of fatigue.
Which of the following actions is best for the nurse to take?
a. Position the client on the right side.
b. Place a humidifier in the client’s room.
c. Assist the client with staged coughing.
d. Schedule a 2-hour rest period for the client.
ANS: C
The client’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 right side may cause a further decrease in
oxygen saturation because perfusion will be directed more toward the more poorly
ventilated lung.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
5. The nurse is caring for an obese client with left lower lobe pneumonia. Which of the
following positions should the nurse place the client in for optimal gas exchange?
a. Left lateral
b. Right lateral
c. Tripod position.
d. High Fowler’s position
ANS: B
The client should be positioned with the “good” lung in the dependent position to improve
the match between ventilation and perfusion. The obese client’s abdomen will limit
respiratory excursion when sitting in the high Fowler’s or tripod positions.
DIF: Cognitive Level: Application TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
6. The nurse is admitting a client who is in possible respiratory failure with a high PaCO2.
Which of the following assessment information will be of most concern to the nurse?
a. The client is somnolent.
b. The client’s SpO2 is 90%.
c. The client complains of weakness.
d. The client’s blood pressure is 162/94 mmHg.
ANS: A
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