Ch. 67 Lewis ARF & ARDS Exam Questions with Complete Solutions
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Course
ARF
Institution
ARF
When prone positioning is used for a patient with acute respiratory distress syndrome (ARDS),
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...
Ch. 67 Lewis ARF & ARDS Exam
Questions with Complete Solutions
When prone positioning is used for a patient with acute respiratory distress syndrome (ARDS),
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 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.
The nurse assesses vital signs for a patient admitted 2 days ago with gram-negative sepsis:
temperature of 101.2° F, blood pressure of 90/56 mm Hg, pulse of 92 beats/min, and
respirations of 34 breaths/min. 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 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.
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. Give enteral feedings at no more than 10 mL/hr.
c. Suction the endotracheal tube every 2 to 4 hours.
d. Limit the use of positive end-expiratory pressure. - ANSWER 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.
A patient admitted with acute respiratory failure has ineffective airway clearance related to
thick secretions. Which nursing intervention would specifically address this patient problem?
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 above 93%. - ANSWER 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) 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.
A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving
mechanical ventilation develops a right pneumothorax. Which collaborative action will
the nurse anticipate next?
a. Increase the tidal volume and respiratory rate.
b. Decrease the fraction of inspired oxygen (FIO2).
c. Perform endotracheal suctioning more frequently.
d. Lower the positive end-expiratory pressure (PEEP). - ANSWER 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 another pneumothorax.
After receiving change-of-shift report on a medical unit, which patient should the nurse assess
first?
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