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Respiratory Failure and Acute Respiratory Distress Syndrome Lewis Ch.68
Terms in this set (30)
When explaining respiratory failure to the patient's family, what should the nurse use as an accurate description?
a. The absence of ventilation
b. Any episode in which part of the airway is obstructed
c. Inadequate gas exchange to meet the metabolic needs of the body
d. An episode of acute hypoxemia caused by a pulmonary dysfunction
c. Respiratory failure results when the transfer of oxygen
or carbon dioxide function of the respiratory system is
impaired and, although the definition is determined by PaO2
levels, the major factor in respiratory failure is
inadequate gas exchange to meet tissue oxygen (O2
Absence of ventilation is respiratory arrest and partial
airway obstruction may not necessarily cause respiratory
failure. Acute hypoxemia may be caused by factors other
than pulmonary dysfunction
Which descriptions are characteristic of hypoxemic respiratory failure (select all that apply)?
a. Referred to as ventilatory failure
b. Primary problem is inadequate O2 transfer
c. Risk of inadequate O2
saturation of hemoglobin exists
d. Body is unable to compensate for acidemia of increased PaCO2
e. Most often caused by ventilation-perfusion (V/Q) mismatch and shunt
f. Exists when PaO2
is 60 mm Hg or less, even when O2
is administered at 60%
b, c, e, f. Hypoxemic respiratory failure is often caused
by ventilation-perfusion (V/Q) mismatch and shunt. It is
called oxygenation failure because the primary problem is
inadequate oxygen transfer. There is a risk of inadequate
oxygen saturation of hemoglobin and it exists when PaO2
is 60 mm Hg or less, even when oxygen is administered at
60%. Ventilatory failure is hypercapnic respiratory failure.
Hypercapnic respiratory failure results from an imbalance
between ventilatory supply and ventilatory demand and the
body is unable to compensate for the acidemia of increased
When teaching the patient about what was happening when experiencing an intrapulmonary shunt, which
explanation is accurate?
a. This occurs when an obstruction impairs the flow of blood to the ventilated areas of the lung.
b. This occurs when blood passes through an anatomic channel in the heart and bypasses the lungs.
c. This occurs when blood flows through the capillaries in the lungs without participating in gas exchange.
d. Gas exchange across the alveolar capillary interface is compromised by thickened or damaged alveolar
c. Intrapulmonary shunt occurs when blood flows through
the capillaries in the lungs without participating in gas
exchange (e.g., acute respiratory distress syndrome
[ARDS], pneumonia). Obstruction impairs the flow of
blood to the ventilated areas of the lung in a V/Q mismatch
ratio greater than 1 (e.g., pulmonary embolus). Blood passes
through an anatomic channel in the heart and bypasses the
lungs with anatomic shunt (e.g., ventricular septal defect).
Gas exchange across the alveolar capillary interface is compromised by thickened or damaged alveolar membranes
in diffusion limitation (e.g., pulmonary fibrosis, ARDS).
When the V/Q lung scan result returns with a mismatch ratio that is greater than 1, which condition should be suspected?
a. Pain c. Pulmonary embolus
b. Atelectasis d. Ventricular septal defect
c. There will be more ventilation than perfusion (V/Q
ratio greater than 1) with a pulmonary embolus. Pain and
atelectasis will cause a V/Q ratio less than 1. A ventricular
septal defect causes an anatomic shunt as the blood
bypasses the lungs.
Which physiologic mechanism of hypoxemia occurs with pulmonary fibrosis?
a. Anatomic shunt c. Intrapulmonary shunt
b. Diffusion limitation d. V/Q mismatch ratio of less than 1
b. Diffusion limitation in pulmonary fibrosis is caused by
thickened alveolar-capillary interface, which slows gas
Which patient with the following manifestations is most likely to develop hypercapnic respiratory failure?
a. Rapid, deep respirations in response to pneumonia
b. Slow, shallow respirations as a result of sedative overdose
c. Large airway resistance as a result of severe bronchospasm
d. Poorly ventilated areas of the lung caused by pulmonary edema
b. Hypercapnic respiratory failure is associated with alveolar
hypoventilation with increases in alveolar and arterial carbon
) and often is caused by problems outside
the lungs. A patient with slow, shallow respirations is not
exchanging enough gas volume to eliminate CO2
. Deep, rapid
respirations reflect hyperventilation and often accompany lung
problems that cause hypoxemic respiratory failure. Pulmonary
edema and large airway resistance cause obstruction of
oxygenation and result in a V/Q mismatch or shunt typical of
hypoxemic respiratory failure.
Which arterial blood gas (ABG) results would most likely indicate acute respiratory failure in a patient with chronic
52 mm Hg, PaCO2
56 mm Hg, pH 7.4
48 mm Hg, PaCO2
54 mm Hg, pH 7.38
b. PaO2 46 mm Hg, PaCO2 52 mm Hg, pH 7.36
50 mm Hg, PaCO2
54 mm Hg, pH 7.28
d. In a patient with normal lung function, respiratory
failure is commonly defined as a PaO2 ≤60 mm Hg or a
>45 mm Hg or both. However, because the patient
with chronic pulmonary disease normally maintains low
and high PaCO2
, acute respiratory failure in these
patients can be defined as an acute decrease in PaO2
increase in PaCO2
from the patient's baseline parameters,
accompanied by an acidic pH. The pH of 7.28 reflects an
acidemia and a loss of compensation in the patient with
chronic lung disease.
The patient is being admitted to the intensive care unit (ICU) with hypercapnic respiratory failure. Which
manifestations should the nurse expect to assess in the patient (select all that apply)?
a. Cyanosis d. Respiratory acidosis
b. Metabolic acidosis e. Use of tripod position
c. Morning headache f. Rapid, shallow respirations
c, d, e, f. Morning headache, respiratory acidosis, the use
of tripod position, and rapid, shallow respirations would
be expected. The other manifestations are characteristic of
hypoxemic respiratory failure.
Which assessment finding should cause the nurse to suspect the early onset of hypoxemia?
a. Restlessness c. Central cyanosis
b. Hypotension d. Cardiac dysrhythmias
a. Because the brain is very sensitive to a decrease in
oxygen delivery, restlessness, agitation, disorientation,
and confusion are early signs of hypoxemia, for which the
nurse should be alert. Mild hypertension is also an early
sign, accompanied by tachycardia. Central cyanosis is an unreliable, late sign of hypoxemia. Cardiac dysrhythmias also occur later
Which changes of aging contribute to the increased risk for respiratory failure in older adults (select all that apply)?
a. Alveolar dilation d. Increased infection risk
b. Increased delirium e. Decreased respiratory muscle strength
c. Changes in vital signs f. Diminished elastic recoil within the airways
a, d, e, f. Changes from aging that increase the older
adult's risk for respiratory failure include alveolar dilation,
increased risk for infection, decreased respiratory muscle
strength, and diminished elastic recoil in the airways.
Although delirium can complicate ventilator management,
it does not increase the older patient's risk for respiratory
failure. The older adult's blood pressure (BP) and heart rate
(HR) increase but this does not affect the risk for respiratory
failure. The ventilatory capacity is decreased and the larger
air spaces decrease the surface area for gas exchange, which
increases the risk.
The nurse assesses that a patient in respiratory distress is developing respiratory fatigue and the risk of respiratory
arrest when the patient displays which behavior?
a. Cannot breathe unless he is sitting upright c. Has an increased inspiratory-expiratory (I/E) ratio
b. Uses the abdominal muscles during expiration d. Has a change in respiratory rate from rapid to slow
d. The increase in respiratory rate required to blow off
predisposes to respiratory muscle fatigue.
The slowing of a rapid rate in a patient in acute distress
indicates tiring and the possibility of respiratory arrest
unless ventilatory assistance is provided. A decreased
inspiratory-expiratory (I/E) ratio, orthopnea, and accessory
muscle use are common findings in respiratory distress but
do not necessarily signal respiratory fatigue or arrest.
A patient has a PaO2
of 50 mm Hg and a PaCO2
of 42 mm Hg because of an intrapulmonary shunt. Which therapy is
the patient most likely to respond best to?
a. Positive pressure ventilation
b. Oxygen administration at a FIO2 of 100%
c. Administration of O2
per nasal cannula at 1 to 3 L/min
d. Clearance of airway secretions with coughing and suctioning
a. Patients with a shunt are usually more hypoxemic than
patients with a V/Q mismatch because the alveoli are filled with fluid, which prevents gas exchange. Hypoxemia
resulting from an intrapulmonary shunt is usually not
responsive to high O2
concentrations and the patient will
usually require positive pressure ventilation. Hypoxemia
associated with a V/Q mismatch usually responds favorably
administration at 1 to 3 L/min by nasal cannula.
Removal of secretions with coughing and suctioning is
generally not effective in reversing an acute hypoxemia
resulting from a shunt.
A patient with a massive hemothorax and pneumothorax has absent breath sounds in the right lung. To promote
improved V/Q matching, how should the nurse position the patient?
a. On the left side c. In a reclining chair bed
b. On the right side d. Supine with the head of the bed elevated
a. When there is impaired function of one lung, the patient
should be positioned with the unaffected lung in the
dependent position to promote perfusion to the functioning
tissue. If the diseased lung is positioned dependently, more
V/Q mismatch would occur. The head of the bed may be
elevated or a reclining chair may be used, with the patient
positioned on the unaffected side, to maximize thoracic
expansion if the patient has increased work of breathing.
A patient in hypercapnic respiratory failure has a nursing diagnosis of ineffective airway clearance related to
increasing exhaustion. What is an appropriate nursing intervention for this patient?
a. Inserting an oral airway c. Teaching the patient huff coughing
b. Performing augmented coughing d. Teaching the patient slow pursed lip breathing
b. Augmented coughing is done by applying pressure on
the abdominal muscles at the beginning of expiration.
This type of coughing helps to increase abdominal
pressure and expiratory flow to assist the cough to remove
secretions in the patient who is exhausted. An oral airway
is used only if there is a possibility that the tongue will
obstruct the airway. Huff coughing prevents the glottis
from closing during the cough and works well for patients
with chronic obstructive pulmonary disease (COPD) to
clear central airways. Slow pursed lip breathing allows
more time for expiration and prevents small bronchioles
The patient with a history of heart failure and acute respiratory failure has thick secretions that she is having
difficulty coughing up. Which intervention would best help to mobilize her secretions?
a. Administer more IV fluid c. Provide O2
by aerosol mask
b. Perform postural drainage d. Suction airways nasopharyngeally
c. For the patient with a history of heart failure, current
acute respiratory failure, and thick secretions, the best
intervention is to liquefy the secretions with either aerosol
mask or using normal saline administered by a nebulizer.
Excess IV fluid may cause cardiovascular distress and the
patient probably would not tolerate postural drainage with
her history. Suctioning thick secretions without thinning
them is difficult and increases the patient's difficulty in
maintaining oxygenation. With copious secretions, this
could be done after thinning the secretions.
Priority Decision: After endotracheal intubation and mechanical ventilation have been started, a patient in
respiratory failure becomes very agitated and is breathing asynchronously with the ventilator. What is it most
important for the nurse to do first?
a. Evaluate the patient's pain level, ABGs, and electrolyte values
b. Sedate the patient to unconsciousness to eliminate patient awareness
c. Administer the PRN vecuronium (Norcuron) to promote synchronous ventilations
d. Slow the rate of ventilations provided by the ventilator to allow for spontaneous breathing by the patient
a. It is most important to assess the patient for the cause
of the restlessness and agitation (e.g., pain, hypoxemia,
electrolyte imbalances) and treat the underlying cause
before sedating the patient. Although sedation, analgesia,
and neuromuscular blockade are often used to control
agitation and pain, these treatments may contribute to
prolonged ventilator support and hospital days.
What is the primary reason that hemodynamic monitoring is instituted in severe respiratory failure?
a. To detect V/Q mismatches
b. To continuously measure the arterial BP
c. To evaluate oxygenation and ventilation status
d. To evaluate cardiac status and blood flow to tissues
d. Hemodynamic monitoring with a pulmonary artery
catheter is instituted in severe respiratory failure to
determine the amount of blood flow to tissues and the
response of the lungs and heart to hypoxemia. Continuous
BP monitoring may be performed but BP is a reflection of
cardiac activity, which can be determined by the pulmonary
artery catheter findings. Arterial blood gases (ABGs) are
important to evaluate oxygenation and ventilation status and
Patients with acute respiratory failure will have drug therapy to meet their individual needs. Which drugs will meet
the goal of reducing pulmonary congestion (select all that apply)?
a. Morphine d. Albuterol (Ventolin)
b. Furosemide (Lasix) e. Ceftriaxone (Rocephin)
c. Nitroglycerin (Tridil) f. Methylprednisolone (Solu-Medrol)
a, b, c. Morphine and nitroglycerin (e.g., Tridil) will
decrease pulmonary congestion caused by heart failure; IV
diuretics (e.g., furosemide [Lasix]) are also used. Inhaled
albuterol (Ventolin) or metaproterenol (Alupent) will relieve
bronchospasms. Ceftriaxone (Rocephin) and azithromycin
(Zithromax) are used to treat pulmonary infections.
Methylprednisolone (Solu-Medrol), an IV corticosteroid, will reduce airway inflammation. Morphine is also used to
decrease anxiety, agitation, and pain.
In caring for a patient in acute respiratory failure, the nurse recognizes that noninvasive positive pressure ventilation
(NIPPV) may be indicated for which patient?
a. Is comatose and has high oxygen requirements
b. Has copious secretions that require frequent suctioning
c. Responds to hourly bronchodilator nebulization treatments
d. Is alert and cooperative but has increasing respiratory exhaustion
d. Noninvasive positive pressure ventilation (NIPPV)
involves the application of a face mask and delivery of
a volume of air under inspiratory pressure. Because the
device is worn externally, the patient must be able to
cooperate in its use and frequent access to the airway for
suctioning or inhaled medications must not be necessary. It
is not indicated when high levels of oxygen are needed or
respirations are absent.
The patient progressed from acute lung injury to acute respiratory distress syndrome (ARDS). He is on the ventilator
and receiving propofol (Diprivan) for sedation and fentanyl (Sublimaze) to decrease anxiety, agitation, and pain
in order to decrease his work of breathing, O2
consumption, carbon dioxide production, and risk of injury. What
intervention is recommended in caring for this patient?
a. A sedation holiday c. Keeping his legs still to avoid dislodging the airway
b. Monitoring for hypermetabolism d. Repositioning him every 4 hours to decrease agitation
a. A sedation holiday is needed to assess the patient's
condition and readiness to extubate. A hypermetabolic state
occurs with critical illness. With malnourished patients,
enteral or parenteral nutrition is started within 24 hours;
with well-nourished patients it is started within 3 days.
With these medications, the patient will be assessed for
cardiopulmonary depression. Venous thromboembolism
prophylaxis will be used but there is no reason to keep the
legs still. Repositioning the patient every 2 hours may help
to decrease discomfort and agitation
Although ARDS may result from direct lung injury or indirect lung injury as a result of systemic inflammatory response
syndrome (SIRS), the nurse is aware that ARDS is most likely to occur in the patient with a host insult resulting from
a. sepsis. c. prolonged hypotension.
b. oxygen toxicity. d. cardiopulmonary bypass.
a. Although ARDS may occur in the patient who has
virtually any severe illness and may be both a cause and a
result of systemic inflammatory response syndrome (SIRS),
the most common precipitating insults of ARDS are sepsis,
gastric aspiration, and severe massive trauma.
What are the primary pathophysiologic changes that occur in the injury or exudative phase of ARDS (select all
a. Atelectasis d. Hyaline membranes line the alveoli
b. Shortness of breath e. Influx of neutrophils, monocytes, and lymphocytes
c. Interstitial and alveolar edema
22. a, c, d. The injury or exudative phase is the early phase of
ARDS when atelectasis and interstitial and alveoli edema
occur and hyaline membranes composed of necrotic cells,
protein, and fibrin line the alveoli. Together, these decrease
gas exchange capability and lung compliance. Shortness
of breath occurs but it is not a physiologic change. The
increased inflammation and proliferation of fibroblasts
occurs in the reparative or proliferative phase of ARDS,
which occurs 1 to 2 weeks after the initial lung injury.
In patients with ARDS who survive the acute phase of lung injury, what manifestations are seen when they progress
to the fibrotic phase?
a. Chronic pulmonary edema and atelectasis
b. Resolution of edema and healing of lung tissue
c. Continued hypoxemia because of diffusion limitation
d. Increased lung compliance caused by the breakdown of fibrotic tissue
c. In the fibrotic phase of ARDS, diffuse scarring and
fibrosis of the lungs occur, resulting in decreased surface
area for gas exchange and continued hypoxemia caused
by diffusion limitation. Although edema is resolved, lung
compliance is decreased because of interstitial fibrosis.
Long-term mechanical ventilation is required. The patient
has a poor prognosis for survival.
In caring for the patient with ARDS, what is the most characteristic sign the nurse would expect the patient to exhibit?
a. Refractory hypoxemia c. Progressive hypercapnia
b. Bronchial breath sounds d. Increased pulmonary artery wedge pressure (PAWP)
a. Refractory hypoxemia, hypoxemia that does not respond
to increasing concentrations of oxygenation by any route,
is a hallmark of ARDS and is always present. Bronchial
breath sounds may be associated with the progression of
levels may be normal until the patient is no
longer able to compensate in response to the hypoxemia.
Pulmonary artery wedge pressure (PAWP) that is normally
elevated in cardiogenic pulmonary edema is normal in the
pulmonary edema of ARDS.
The nurse suspects the early stage of ARDS in any seriously ill patient who manifests what?
a. Develops respiratory acidosis c. Exhibits dyspnea and restlessness
b. Has diffuse crackles and rhonchi d. Has a decreased PaO2 and an increased PaCO2
c. Early signs of ARDS are insidious and difficult to
detect but the nurse should be alert for any early signs
of hypoxemia, such as dyspnea, restlessness, tachypnea,
cough, and decreased mentation, in patients at risk for
ARDS. Abnormal findings on physical examination or
diagnostic studies, such as adventitious lung sounds, signs
of respiratory distress, respiratory alkalosis, or decreasing
, are usually indications that ARDS has progressed
beyond the initial stages.
A patient with ARDS has a nursing diagnosis of risk for infection. To detect the presence of infections commonly
associated with ARDS, what should the nurse monitor?
a. Gastric aspirate for pH and blood c. Subcutaneous emphysema of the face, neck, and chest
b. Quality, quantity, and consistency of sputum d. Mucous membranes of the oral cavity for open lesions
b. Ventilator-associated pneumonia (VAP) is one of the
most common complications of ARDS. Early detection
requires frequent monitoring of sputum smears and cultures and assessment of the quality, quantity, and consistency
of sputum. Prevention of VAP is done with strict infection
control measures, ventilator bundle protocol, and subglottal
secretion drainage. Blood in gastric aspirate may indicate
a stress ulcer and subcutaneous emphysema of the face,
neck, and chest occurs with barotrauma during mechanical
ventilation. Oral infections may result from prophylactic
antibiotics and impaired host defenses but are not common.
The best patient response to treatment of ARDS occurs when initial management includes what?
a. Treatment of the underlying condition c. Treatment with diuretics and mild fluid restriction
b. Administration of prophylactic antibiotics d. Endotracheal intubation and mechanical ventilation
a. Because ARDS is precipitated by a physiologic insult,
a critical factor in its prevention and early management
is treatment of the underlying condition. Prophylactic
antibiotics, treatment with diuretics and fluid restriction,
and mechanical ventilation are also used as ARDS
When mechanical ventilation is used for the patient with ARDS, what is the rationale for applying positive end-
expiratory pressure (PEEP)?
a. Prevent alveolar collapse and open up collapsed alveoli
b. Permit smaller tidal volumes with permissive hypercapnia
c. Promote complete emptying of the lungs during exhalation
d. Permit extracorporeal oxygenation and carbon dioxide removal outside the body
a. Positive end-expiratory pressure (PEEP) used with
mechanical ventilation applies positive pressure to the
airway and lungs at the end of exhalation, keeping the lung
partially expanded and preventing collapse of the alveoli
and helping to open up collapsed alveoli. Permissive
hypercapnia is allowed when the patient with ARDS is
ventilated with smaller tidal volumes to prevent barotrauma.
Extracorporeal membrane oxygenation and extracorporeal
removal involve passing blood across a gas-exchanging
membrane outside the body and then returning oxygenated
blood to the body.
The nurse suspects that a patient with PEEP is experiencing negative effects of this ventilatory maneuver when
which of the following is assessed?
a. Increasing PaO2 c. Decreasing heart rate (HR)
b. Decreasing blood pressure d. Increasing central venous pressure (CVP)
b. PEEP increases intrathoracic and intrapulmonic
pressures, compresses the pulmonary capillary bed, and
reduces blood return to both the right and left sides of
the heart. Increased PaO2
is an expected effect of PEEP.
Preload (CVP) and cardiac output (CO) are decreased,
often with a dramatic decrease in BP.
Prone positioning is considered for a patient with ARDS who has not responded to other measures to increase PaO2
The nurse knows that this strategy will
a. increase the mobilization of pulmonary secretions.
b. decrease the workload of the diaphragm and intercostal muscles.
c. promote opening of atelectatic alveoli in the upper portion of the lung.
d. promote perfusion of nonatelectatic alveoli in the anterior portion of the lung.
d. When a patient with ARDS is supine, alveoli in the
posterior areas of the lung are dependent and fluid-filled
and the heart and mediastinal contents place more pressure
on the lungs, predisposing to atelectasis. If the patient is
turned prone, air-filled nonatelectatic alveoli in the anterior
portion of the lung receive more blood and perfusion
may be better matched to ventilation, causing less V/Q
mismatch. Lateral rotation therapy is used to stimulate
postural drainage and help mobilize pulmonary secretions.
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