Ch 67 ARDS/ARF1. To evaluate the
effectiveness of ordered interventions for
a patient with ventilatory failure, which
diagnostic test will be most useful to the
nurse?
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 -
ANSWER-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 patients ventilatory failure.
2. While caring for a patient who has been
admitted with a pulmonary embolism, the
nurse notes a change in the patients
oxygen saturation (SpO2) from 94% to
88%. Which action should the nurse take
next?
a. Increase the oxygen flow rate.
b. Suction the patients oropharynx.
,c. Instruct the patient to cough and deep
breathe.
d. Help the patient to sit in a more upright
position. - ANSWER-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.
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 - ANSWER-
ANS: B
The patients 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
effectiveness of ordered interventions for
a patient with ventilatory failure, which
diagnostic test will be most useful to the
nurse?
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 -
ANSWER-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 patients ventilatory failure.
2. While caring for a patient who has been
admitted with a pulmonary embolism, the
nurse notes a change in the patients
oxygen saturation (SpO2) from 94% to
88%. Which action should the nurse take
next?
a. Increase the oxygen flow rate.
b. Suction the patients oropharynx.
,c. Instruct the patient to cough and deep
breathe.
d. Help the patient to sit in a more upright
position. - ANSWER-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.
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 - ANSWER-
ANS: B
The patients 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
