ARF/ARDS Test 2024|Questions with Complete Solutions
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Course
ARF
Institution
ARF
A finding indicating to the nurse that a 22-year-old patient with respiratory distress is in acute
respiratory failure includes a
a. shallow breathing pattern.
b. partial pressure of arterial oxygen (PaO2) of 45 mm Hg.
c. partial pressure of carbon dioxide in arterial gas (PaCO2) of 34 mm Hg.
...
ARF/ARDS Test 2024|Questions with
Complete Solutions
A finding indicating to the nurse that a 22-year-old patient with respiratory distress is in acute
respiratory failure includes a
a. shallow breathing pattern.
b. partial pressure of arterial oxygen (PaO2) of 45 mm Hg.
c. partial pressure of carbon dioxide in arterial gas (PaCO2) of 34 mm Hg.
d. respiratory rate of 32/min. - ANSWER B
Rationale: The PaO2 indicates severe hypoxemia and that the nurse should take immediate
action to correct this problem. Shallow breathing, rapid respiratory rate, and low PaCO2 can be
caused by other factors, such as anxiety or pain.
Cognitive Level: Application Text Reference: p. 1806
Nursing Process: Assessment NCLEX: Physiological Integrity
,While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes
a change in the patient's arterial oxyhemoglobin saturation (SpO2) from 94% to 88%. The
nurse will
a. assist the patient to cough and deep-breathe.
b. help the patient to sit in a more upright position.
c. suction the patient's oropharynx.
d. increase the oxygen flow rate. - ANSWER D
Rationale: 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.
Cognitive Level: Application Text Reference: pp. 1802, 1807
A patient with hypercapnic respiratory failure has a respiratory rate of 8 and an SpO2 of 89%.
The patient is increasingly lethargic. Which collaborative 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 bilevel positive pressure ventilation (BiPAP) - ANSWER B
Rationale: 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. BiPAP requires that the patient initiate an adequate respiratory
rate to allow adequate gas exchange.
Cognitive Level: Application Text Reference: pp. 1807-1808, 1810
Nursing Process: Planning NCLEX: Physiological Integrity
, A patient in acute respiratory failure as a complication of COPD has a PaCO2 of 65 mm Hg, rhonchi
audible in the right lung, and marked fatigue with a weak cough. The nurse will plan to
a. allow the patient to rest to help conserve energy.
b. arrange for a humidifier to be placed in the patient's room.
c. position the patient on the right side with the head of the bed elevated.
d. assist the patient with augmented coughing to remove respiratory secretions. - ANSWER D
Rationale: The patient's assessment indicates that assisted coughing is needed to help
remove secretions, which will improve PaCO2 and will also help to correct fatigue. If the
patient is allowed to rest, the PaCO2 will increase. Humidification may help loosen secretions,
but the weak cough effort will prevent the secretions from being cleared. The patient should
be positioned with the good lung down to improve gas exchange.
Cognitive Level: Application Text Reference: p. 1809
When the nurse is caring for an obese patient with left lower-lobe pneumonia, gas exchange
will be best when the patient is positioned
a. on the left side.
b. on the right side.
c. in the high-Fowler's position.
d. in the tripod position. - ANSWER B
Rationale: 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.
Cognitive Level: Comprehension Text Reference: pp. 1809-1810
Nursing Process: Implementation NCLEX: Physiological Integrity
The nurse is caring for a patient who was hospitalized 2 days earlier with aspiration pneumonia.
Which assessment information is most important to communicate to the health care provider?
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