Quiz :Acute Respiratory Distress Syndrome (ARDS)

1. The physician has inserted a chest tube in a client with a pneumothorax. The nurse should evaluate the effectiveness of the chest tube:

For administration of oxygen

To promote formation of lung scar tissue

To insert antibiotics into the pleural space

To remove air and fluid

Chest tubes are used to re-expand the lung and remove air and fluid.

Explanation

Chest tubes are used to re-expand the lung and remove air and fluid.

2. A client with ARDS is showing signs of increased dyspnea. The nurse reviews a report of ABGs that recently arrived:pH 7.35PaC02 25 mm HgHC03 22 mEq/LPa02 95 mm HgWhich finding should the nurse report to the physician?

PH

PaC02

HC03

Pa02

The normal range for PaC02 is 35-45; this is very low.

Explanation

The normal range for PaC02 is 35-45; this is very low.

3. Which one of the following assessments is most appropriate for determining the correct placement of an endotracheal tube in a mechanically ventilated client?

Assessing the client's skin color

Monitoring the respiratory rate

Verifying the amount of cuff inflation

Auscultating breath sounds bilaterally

Checking for breath sounds on both sides is crucial! If you only hear lung sounds on one side, the tube is not inserted correctly. Xray is often done when a patient is intubated.

Explanation

Checking for breath sounds on both sides is crucial! If you only hear lung sounds on one side, the tube is not inserted correctly. Xray is often done when a patient is intubated.

4. A client is admitted to the ER with a headache, weakness, and slight confusion. The physician diagnoses carbon monoxide poisoning. What should the nurse do first?

Initiate gastric lavage

Maintain body temperature

Administer 100% oxygen by mask

Obtain a psychiatric referral

You need to "knock off" the carbon monoxide with oxygen in an attempt to replace it at its receptor sites.

Explanation

You need to "knock off" the carbon monoxide with oxygen in an attempt to replace it at its receptor sites.

5. Which of the following interventions should the nurse anticipate in a client who has been diagnosed with ARDS?

Tracheostomy

Use of a nasal cannula

Mechanical ventilation

Insertion of a chest tube

Patients with ARDS will need intubation and mechanical ventilation.

Explanation

Patients with ARDS will need intubation and mechanical ventilation.

6. A confused client with carbon monoxide poisoning experiences dizziness when ambulating to the bathroom. The nurse should:

Put all four side rails up

Ask the unlicensed personnel to place restraints on the client's wrists

Request that the client's roommate put the call light on when he tries to get out of bed

Check on the client at regular intervals to ascertain the need for toileting

Frequent rounding! Restraints are not a first option - so all four side rails and wrist restraints are out. The client's roommate is not your assistant.

Explanation

Frequent rounding! Restraints are not a first option - so all four side rails and wrist restraints are out. The client's roommate is not your assistant.

7. For a client with rub fractures and a pneumothorax, the physician prescribes morphine sulfate, 1 to 2 mg/hour, given IV as needed for pain. The nursing care goal is to provide adequate pain control so that the client can breathe effectively. Which of the following outcomes would indicate successful achievement of this goal?

Pain rating of 0 on a scale of 0-10 by the client

Decreased client anxiety

Respiratory rate of 26 breaths/minute

Pa02 of 70 mm Hg

Look at the question again - "the nursing care goal is to provide ADEQUATE PAIN RELIEF". Only the first answer choice addresses that.

Explanation

Look at the question again - "the nursing care goal is to provide ADEQUATE PAIN RELIEF". Only the first answer choice addresses that.

8. Which of the following nursing interventions would promote effective airway clearance in a client with ARDS?

Administering oxygen every 2 hours

Turning the client every 4 hours

Administering sedatives to promote rest

Suctioning if cough is ineffective

Look at the question again: would PROMOTE AIRWAY CLEARANCE. Only suctioning will do that. Every 2 hours is not often enough - they will be on continuous oxygen. Turning every 4 hours is not often enough, and you want to be VERY careful with sedatives with ARDS patients - and sedatives won't help promote airway clearance anyway!

Explanation

Look at the question again: would PROMOTE AIRWAY CLEARANCE. Only suctioning will do that. Every 2 hours is not often enough - they will be on continuous oxygen. Turning every 4 hours is not often enough, and you want to be VERY careful with sedatives with ARDS patients - and sedatives won't help promote airway clearance anyway!

9. A 21-year old male is transported by ambulance to the emergency department after a serious automobile accident. He complains of severe pain in his right chest where he struck the steering wheel. Which is the primary client goal at this time?

Reduce the client's anxiety

Maintain adequate oxygenation

Decrease chest pain

Maintain adequate circulating volume

Blunt chest trauma may lead to respiratory failure, and maintenance of adequate oxygenation is the priority for the client. Decreasing the client's anxiety is related to maintaining effective respirations and oxygenation. Although pain is distressing to the client and can increase anxiety and decrease effectiveness, pain control is secondary to maintaining oxygenation. Maintaining adequate circulatory volume is also secondary to maintaining adequate oxygenation.

Explanation

Blunt chest trauma may lead to respiratory failure, and maintenance of adequate oxygenation is the priority for the client. Decreasing the client's anxiety is related to maintaining effective respirations and oxygenation. Although pain is distressing to the client and can increase anxiety and decrease effectiveness, pain control is secondary to maintaining oxygenation. Maintaining adequate circulatory volume is also secondary to maintaining adequate oxygenation.

10. A client with rib fractures and a pneumothorax has a chest tube inserted that is connected to water-seal drainage. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. What is the significance of this fluctuation?

An obstruction is present in the chest tube

The client is developing subcutaneous emphysema

The chest tube system is functioning properly

There is a leak in the chest tube system

Fluctuation of fluid in the water-seal column with respirations indicates that the system is functioning properly. If an obstruction were present in the chest tube, fluid fluctuation would be absent. Subcutaneous emphysema occurs when air pockets can be palpated beneath the client's skin around the chest tube insertion site. A leak in the system is indicated when continuous bubbling occurs in the water-seal column.

Explanation

Fluctuation of fluid in the water-seal column with respirations indicates that the system is functioning properly. If an obstruction were present in the chest tube, fluid fluctuation would be absent. Subcutaneous emphysema occurs when air pockets can be palpated beneath the client's skin around the chest tube insertion site. A leak in the system is indicated when continuous bubbling occurs in the water-seal column.

11. Which of the following findings would suggest pneumothorax in a trauma victim?

Pronounced crackles

Inspiratory wheezing

Dullness on percussion

Absent breath sounds

Pneumothorax means that the lung has basically collapsed and is not functioning. The nurse would hear no movement of air on auscultation. Movement of air through mucous produces crackles. Wheezing occurs when airways become obstructed/narrowed. Dullness on percussion indicates increased density of lung tissue, usually caused by accumulation of fluid.

Explanation

Pneumothorax means that the lung has basically collapsed and is not functioning. The nurse would hear no movement of air on auscultation. Movement of air through mucous produces crackles. Wheezing occurs when airways become obstructed/narrowed. Dullness on percussion indicates increased density of lung tissue, usually caused by accumulation of fluid.

12. The nurse interprets which of the following as an early sign of ARDS?

Elevated carbon dioxide level

Hypoxia not responsive to oxygen therapy

Metabolic acidosis

Severe, unexplained electrolyte imbalance

A hallmark of early ARDS is refractive hypoxia (hypoxia that doesn't get better with treatment).

Explanation

A hallmark of early ARDS is refractive hypoxia (hypoxia that doesn't get better with treatment).

13. A client has the following ABG values:pH 7.52Pa02 50 mm HgPaC02 28 mm HgHC03 24 mEq/LBased on the client's Pa02, which of these conclusions would be accurate?

The client is severely hypoxic

The oxygen level is low but poses no risk for the client

The client's Pa02 level is within normal range

The client requires oxygen therapy with very low oxygen concentrations

Normal Pa02 is 80-100 mm Hg; this client is severely hypoxic.

Explanation

Normal Pa02 is 80-100 mm Hg; this client is severely hypoxic.

14. A client who is recovering from chest trauma is to be discharged home with a chest tube drainage system intact. The nurse should instruct the client to call the physician for which of the following?

Respiratory rate greater than 16 breaths/minute

Continuous bubbling in the water-seal chamber

Fluid in the chest tube

Fluctuation of fluid in the water-seal chamber

Continuous bubbling in the water-seal chamber indicates a leak in the system, and the client needs to be instructed to notify the physician if continuous bubbling occurs. A respiratory rate of more than 16 breaths/minute may not be unusual and does not necessarily warrant a call to the physician. Fluid in the chest tube is expected, as is fluctuation of the fluid in the water-seal chamber.

Explanation

Continuous bubbling in the water-seal chamber indicates a leak in the system, and the client needs to be instructed to notify the physician if continuous bubbling occurs. A respiratory rate of more than 16 breaths/minute may not be unusual and does not necessarily warrant a call to the physician. Fluid in the chest tube is expected, as is fluctuation of the fluid in the water-seal chamber.

15. A client undergoes surgery to repair lung injuries. Postop orders include the transfusion of one unit of packed red blood cells at a rate of 60 mL/hour. How long would this transfusion take?

2 hours

4 hours

6 hours

8 hours

A unit of PRBCs is about 250mLs. 250 divided by 6 is around 4 - you cannot infuse a unit of blood for more than 4 hours.

Explanation

A unit of PRBCs is about 250mLs. 250 divided by 6 is around 4 - you cannot infuse a unit of blood for more than 4 hours.

16. A client's chest tube is to be removed by the physician. Which of the following items should the nurse have ready to be placed directly over the wound when the chest tube is removed?

Butterfly dressing

Montgomery strap

Fine-mesh gauze dressing

Petroleum gauze dressing

The petroleum gauze dressing creates an airtight seal that prevents air leakage in either direction. Mesh gauze would allow air movement. Montgomery straps are most often used with abdominal dressings, and butterfly dressings are used in lieu of stitches in smaller clean open cuts.

Explanation

The petroleum gauze dressing creates an airtight seal that prevents air leakage in either direction. Mesh gauze would allow air movement. Montgomery straps are most often used with abdominal dressings, and butterfly dressings are used in lieu of stitches in smaller clean open cuts.

17. Which of the following conditions can place a client at risk for ARDS?

Septic shock

COPD

Asthma

Heart failure

Septic shock is a common cause of ARDS. Other common causes: hypovolemic shock and GI content aspiration.

Explanation

Septic shock is a common cause of ARDS. Other common causes: hypovolemic shock and GI content aspiration.

18. The nurse has calculated a low P/F ratio < 150 for a client with ARDS. The nurse should place the client in which position to improve oxygenation, ventilation distribution, and drainage of secretions?

Supine

Semi-fowlers

Lateral side

Prone

Prone position in ARDS is used to improve oxygenation, ventilation, and perfusion and help mobilize secretions.

Explanation

Prone position in ARDS is used to improve oxygenation, ventilation, and perfusion and help mobilize secretions.

19. A nurse is to administer 10 mg of morphine sulfate to a client with three fractures ribs. The available concentration for this drug is 15mg/mL. How many milliliters should the nurse administer? Round to one decimal point. Answer: _________ mL's.

10mg/X mL = 15mg/1mL
15mg x XmL = 10mg X 1 mL
15X = 10
X = 0.6667
X = 0.7 mL

Explanation

10mg/X mL = 15mg/1mL
15mg x XmL = 10mg X 1 mL
15X = 10
X = 0.6667
X = 0.7 mL

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20. The primary reason for infusing blood at a rate of 60 mL/hour is to help prevent which of the following complications?

Emboli formation

Fluid volume overload

Red blood cell hemolysis

Allergic reaction

Remember the phrase "blood is thicker than water"? It's true - literally. Blood has more density and can cause more fluid volume overload than the same amount of IV fluids. None of the other things are related to rapid infusion.

Explanation

Remember the phrase "blood is thicker than water"? It's true - literally. Blood has more density and can cause more fluid volume overload than the same amount of IV fluids. None of the other things are related to rapid infusion.

21. A client has been in a car accident and the nurse is assessing for possible pneumothorax. The nurse should assess for:

Sudden, sharp chest pain

Wheezing breath sounds over affected side

Hemoptysis

Cyanosis

Signs of pneumothorax: sudden, sharp chest pain; tachypnea; tachycardia; absent or diminished breath sounds over the affected lung; anxiety; restlessness. Cyanosis MAY be seen, but is not ALWAYS seen.

Explanation

Signs of pneumothorax: sudden, sharp chest pain; tachypnea; tachycardia; absent or diminished breath sounds over the affected lung; anxiety; restlessness. Cyanosis MAY be seen, but is not ALWAYS seen.

22. Which of the following interventions would be most likely to prevent the development of ARDS?

Teaching cigarette smoking cessation

Maintaining adequate serum potassium levels

Monitoring clients for signs of hypercapnia

Replacing fluids adequately during hypovolemic states

One of the MAJOR risk factors for ARDS is hypovolemic shock.

Explanation

One of the MAJOR risk factors for ARDS is hypovolemic shock.

23. Which of the following are expected outcomes for a client with pulmonary disease?

A relatively matched ventilation-to-perfusion ratio

A low ventilation to perfusion ratio

A high ventilation to perfusion ratio

An equal Pa02 and PaC02 ratio

Definitely want a matched ventilation-perfusion ratio! Ventilation = the oxygen that goes in. Perfusion=the oxygen that gets to all the places that need it. If the ratio is matched, then all the oxygen that goes in gets to where it is needed.

Explanation

Definitely want a matched ventilation-perfusion ratio! Ventilation = the oxygen that goes in. Perfusion=the oxygen that gets to all the places that need it. If the ratio is matched, then all the oxygen that goes in gets to where it is needed.

24. A client with ARDS is on a ventilator. The client's peak inspiratory pressure and spontaneous respiratory rate are increasing, and the P02 is not improving. Using the SBAR technique, the nurse calls the physician with the recommendation for:

Initiating IV sedation

Starting a high protein diet

Providing pain medication

Increasing the ventilator rate

The client is "fighting" the ventilator and needs sedation to help relax. You always want to be careful with sedation and ARDS patients - it is most dangerous when they are not on a ventilator, but you can still oversedate a patient on a ventilator as well. Use only as much as is needed.

Explanation

The client is "fighting" the ventilator and needs sedation to help relax. You always want to be careful with sedation and ARDS patients - it is most dangerous when they are not on a ventilator, but you can still oversedate a patient on a ventilator as well. Use only as much as is needed.

25. A client has the following ABG values:pH 7.52Pa02 50 mm HgPaC02 28 mm HgHC03 24 mEq/LThe nurse determines that which of the following is a possible cause for these findings?

COPD

DKA with Kussmaul's respirations

Myocardial infarction

Pulmonary embolus

PaC02 of 28 mm Hg and Pa02 of 50 mm Hg are both abnormal, and the low Pa02 signifies acute respiratory failure. A PE would cause respiratory distress and anxiety (breathing fast...blowing off their C02). COPD is typically associated with respiratory acidosis and elevated PaC02. DKA is typically associated with metabolic acidosis. An MI doesn't usually cause an acid-base imbalance.

Explanation

PaC02 of 28 mm Hg and Pa02 of 50 mm Hg are both abnormal, and the low Pa02 signifies acute respiratory failure. A PE would cause respiratory distress and anxiety (breathing fast...blowing off their C02). COPD is typically associated with respiratory acidosis and elevated PaC02. DKA is typically associated with metabolic acidosis. An MI doesn't usually cause an acid-base imbalance.

26. A nurse should interpret which of the following as an early sign of a tension pneumothorax in a client with chest trauma?

Diminished bilateral breath sounds

Muffled heart sounds

Respiratory distress

Tracheal deviation

Respiratory distress is a universal finding of a tension pneumothorax. Unilateral, diminished or absent breath sounds is also a common finding (not bilateral). Tracheal deviation is not always present, and is typically a late sign, when it is seen. Muffled heart sounds are seen in pericardial tamponade

Explanation

Respiratory distress is a universal finding of a tension pneumothorax. Unilateral, diminished or absent breath sounds is also a common finding (not bilateral). Tracheal deviation is not always present, and is typically a late sign, when it is seen. Muffled heart sounds are seen in pericardial tamponade

27. Which of the following complications is associated with mechanical ventilation?

GI hemorrhage

Immunosuppression

Increased cardiac output

Pulmonary emboli

GI bleed due to stress ulcers occurs in about 25% of clients on mechanical ventilation - this is why everyone on a ventilator is also on some sort of GI protective medication (Protonix, etc.)

Explanation

GI bleed due to stress ulcers occurs in about 25% of clients on mechanical ventilation - this is why everyone on a ventilator is also on some sort of GI protective medication (Protonix, etc.)

28. The nurse has placed the intubated client with ARDS in prone position for 30 minutes. Which of the following would require the nurse to discontinue prone positioning and return the client to the supine position? Select all that apply.

The family is coming in to visit

The client has increased secretions requiring frequent suctioning

The Sp02 and P02 have decreased

The client is tachycardic with drop in blood pressure

The face has increased skin breakdown and edema

Prone position is used to improve oxygenation, ventilation, and perfusion. The importance of this should be explained to the family. Prone position also provides for increased mobilization of secretions, so "increased secretions requiring frequent suctioning" is actually a good thing. If the oxygen sats are going down and the heart rate is up with a drop in BP, he must be returned to normal position immediately. Facial edema is expected - but actual skin breakdown is not.

Explanation

Prone position is used to improve oxygenation, ventilation, and perfusion. The importance of this should be explained to the family. Prone position also provides for increased mobilization of secretions, so "increased secretions requiring frequent suctioning" is actually a good thing. If the oxygen sats are going down and the heart rate is up with a drop in BP, he must be returned to normal position immediately. Facial edema is expected - but actual skin breakdown is not.

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29. A client with ARDS has fine crackles at the lung bases and the respirations are shallow at a rate of 28 breaths/minute. The client is restless and anxious. In addition to monitoring the arterial blood gas results, the nurse should do which of the following? Select all that apply.

Monitor serum creatinine and BUN levels

Administer a sedative

Keep the head of the bed flat

Administer humidified oxygen

Auscultate the lungs

ARDS is known to cause renal failure and superinfection, so monitoring BUN/Cr is a must. Sedation is given VERY sparingly - the restlessness and anxiety is due to the oxygenation problem - so you need to fix the oxygenation problem, not sedate them. Putting the head of the bed flat would make it harder to breathe. Humidified oxygen would help promote oxygenation and mobilize secretions, and you definitely need to listen to the lungs.

Explanation

ARDS is known to cause renal failure and superinfection, so monitoring BUN/Cr is a must. Sedation is given VERY sparingly - the restlessness and anxiety is due to the oxygenation problem - so you need to fix the oxygenation problem, not sedate them. Putting the head of the bed flat would make it harder to breathe. Humidified oxygen would help promote oxygenation and mobilize secretions, and you definitely need to listen to the lungs.

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