ARF/ARDS MODULE 13 RESP FAILURE ARDS
NCLEX QUESTIONS, RESP FAILURE ARDS NCLEX,
IGGY CH 32 CARE OF CRITICALLY ILL PATIENTS
WITH RESPIRATORY PROBLEMS Q&A
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. Observe for facial symmetry.
b. Notify the health care provider.
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 O2 saturation. The other actions are also appropriate, but
assessment of oxygenation takes priority over other assessments and notification of the health
care provider.
Which actions should the nurse start 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. Give prescribed pantoprazole (Protonix).
d. Elevate the head of the bed to at least 30°.
e. Provide oral care with chlorhexidine (0.12%) solution daily.
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,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.
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%.
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.
It will be most important for the nurse to check pulse oximetry for which of these patients?
a. A patient with emphysema and a respiratory rate of 16
b. A patient with massive obesity who is refusing to get out of bed
c. A patient with pneumonia who has just been admitted to the unit
d. A patient who has just received morphine sulfate for postoperative pain
C
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,Rationale: Hypoxemia and hypoxemic respiratory failure are caused by disorders that
interfere with the transfer of oxygen into the blood, such as pneumonia. The other listed
disorders are more likely to cause problems with hypercapnia because of ventilatory failure.
Cognitive Level: Application Text Reference: pp. 1799-1800
Nursing Process: Assessment NCLEX: Physiological Integrity
The nurse will monitor for clinical manifestations of hypercapnia when a patient in the
emergency department has
a. chest trauma and multiple rib fractures.
b. carbon monoxide poisoning after a house fire.
c. left-sided ventricular failure and acute pulmonary edema.
d. tachypnea and acute respiratory distress syndrome (ARDS).
A
Rationale: Hypercapnia is caused by poor ventilatory effort, which occurs in chest trauma
when rib fractures (or flail chest) decrease lung ventilation. Carbon monoxide poisoning,
acute pulmonary edema, and ARDS are more commonly associated with hypoxemia.
Cognitive Level: Application Text Reference: p. 1800
Nursing Process: Assessment NCLEX: Physiological Integrity
When a patient is diagnosed with pulmonary fibrosis, the nurse will teach the patient about
the risk for poor oxygenation because of
a. too-rapid movement of blood flow through the pulmonary blood vessels.
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, b. incomplete filling of the alveoli with air because of reduced respiratory ability.
c. decreased transfer of oxygen into the blood because of thickening of the alveoli.
d. mismatch between lung ventilation and blood flow through the blood vessels of the lung.
C
Rationale: Pulmonary fibrosis causes the alveolar-capillary interface to become thicker,
which increases the amount of time it takes for gas to diffuse across the membrane. Too-rapid
pulmonary blood flow is another cause of shunt but does not describe the pathology of
pulmonary fibrosis. Decrease in alveolar ventilation will cause hypercapnia. Ventilation and
perfusion are matched in pulmonary fibrosis; the problem is with diffusion.
Cognitive Level: Application Text Reference: p. 1802
Nursing Process: Implementation NCLEX: Physiological Integrity
A patient is diagnosed with a large pulmonary embolism. When explaining to the patient
what has happened to cause respiratory failure, which information will the nurse include?
a. "Oxygen transfer into your blood is slow because of thick membranes between the small
air sacs and the lung circulation."
b. "Thick secretions in your small airways are blocking air from moving into the small air
sacs in your lungs."
c. "Large areas of your lungs are getting good blood flow but are not receiving enough air to
fill the small air sacs."
d. "Blood flow though some areas of your lungs is decreased even though you are taking
adequate breaths."
D
Rationale: A pulmonary embolus limits blood flow but does not affect ventilation, leading to
a ventilation-perfusion mismatch. The response beginning, "Oxygen transfer into your blood
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NCLEX QUESTIONS, RESP FAILURE ARDS NCLEX,
IGGY CH 32 CARE OF CRITICALLY ILL PATIENTS
WITH RESPIRATORY PROBLEMS Q&A
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. Observe for facial symmetry.
b. Notify the health care provider.
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 O2 saturation. The other actions are also appropriate, but
assessment of oxygenation takes priority over other assessments and notification of the health
care provider.
Which actions should the nurse start 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. Give prescribed pantoprazole (Protonix).
d. Elevate the head of the bed to at least 30°.
e. Provide oral care with chlorhexidine (0.12%) solution daily.
Page | 1
,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.
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%.
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.
It will be most important for the nurse to check pulse oximetry for which of these patients?
a. A patient with emphysema and a respiratory rate of 16
b. A patient with massive obesity who is refusing to get out of bed
c. A patient with pneumonia who has just been admitted to the unit
d. A patient who has just received morphine sulfate for postoperative pain
C
Page | 2
,Rationale: Hypoxemia and hypoxemic respiratory failure are caused by disorders that
interfere with the transfer of oxygen into the blood, such as pneumonia. The other listed
disorders are more likely to cause problems with hypercapnia because of ventilatory failure.
Cognitive Level: Application Text Reference: pp. 1799-1800
Nursing Process: Assessment NCLEX: Physiological Integrity
The nurse will monitor for clinical manifestations of hypercapnia when a patient in the
emergency department has
a. chest trauma and multiple rib fractures.
b. carbon monoxide poisoning after a house fire.
c. left-sided ventricular failure and acute pulmonary edema.
d. tachypnea and acute respiratory distress syndrome (ARDS).
A
Rationale: Hypercapnia is caused by poor ventilatory effort, which occurs in chest trauma
when rib fractures (or flail chest) decrease lung ventilation. Carbon monoxide poisoning,
acute pulmonary edema, and ARDS are more commonly associated with hypoxemia.
Cognitive Level: Application Text Reference: p. 1800
Nursing Process: Assessment NCLEX: Physiological Integrity
When a patient is diagnosed with pulmonary fibrosis, the nurse will teach the patient about
the risk for poor oxygenation because of
a. too-rapid movement of blood flow through the pulmonary blood vessels.
Page | 3
, b. incomplete filling of the alveoli with air because of reduced respiratory ability.
c. decreased transfer of oxygen into the blood because of thickening of the alveoli.
d. mismatch between lung ventilation and blood flow through the blood vessels of the lung.
C
Rationale: Pulmonary fibrosis causes the alveolar-capillary interface to become thicker,
which increases the amount of time it takes for gas to diffuse across the membrane. Too-rapid
pulmonary blood flow is another cause of shunt but does not describe the pathology of
pulmonary fibrosis. Decrease in alveolar ventilation will cause hypercapnia. Ventilation and
perfusion are matched in pulmonary fibrosis; the problem is with diffusion.
Cognitive Level: Application Text Reference: p. 1802
Nursing Process: Implementation NCLEX: Physiological Integrity
A patient is diagnosed with a large pulmonary embolism. When explaining to the patient
what has happened to cause respiratory failure, which information will the nurse include?
a. "Oxygen transfer into your blood is slow because of thick membranes between the small
air sacs and the lung circulation."
b. "Thick secretions in your small airways are blocking air from moving into the small air
sacs in your lungs."
c. "Large areas of your lungs are getting good blood flow but are not receiving enough air to
fill the small air sacs."
d. "Blood flow though some areas of your lungs is decreased even though you are taking
adequate breaths."
D
Rationale: A pulmonary embolus limits blood flow but does not affect ventilation, leading to
a ventilation-perfusion mismatch. The response beginning, "Oxygen transfer into your blood
Page | 4
