Normal;header;footer;
14-PAGE 17
Test Bank
Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.
Elsevier items and derived items © 2009, 2005, 2001 by Saunders, an imprint of Elsevier Inc.
...)()()()()()Sole: Introduction to Critical Care Nursing, 5th Edition
Chapter 14: Acute Respiratory Failure
Test Bank
MULTIPLE CHOICE
1.Nursing strategies to prevent ventilator-associated pneumonia include all of the following EXCEPT:
a.drain condensate from the ventilator tubing away from the patient.b.elevate the head of the bed 30 to 45
degrees.c.ensure proper hand hygiene.d.instill normal saline as part of the suctioning procedure.
ANS:D
Normal saline is not recommended as part of the suctioning procedure.
Incorrect:
A: Condensate should be drained away from the patient to avoid drainage back into the patient’s airway.
B: Guidelines recommend elevating the head of bed at 30 to 45 degrees.
C: Hand hygiene is the first line of defense against the spread of infection.
DIF:Cognitive Level: ApplicationREF:Page 461 | Box 14-4
OBJ:Formulate a plan of care for the patient with acute respiratory failure (ARF).
TOP:Nursing Process Step: Implementation
MSC:NCLEX: Physiologic Integrity
2.The patient with acute respiratory distress syndrome (ARDS) would exhibit which of the following symptoms?
a.Decreasing PaO2 levels despite increased FIO2 administrationb.Elevated alveolar surfactant levelsc.Increased
lung compliance with increased FIO2 administrationd.Respiratory acidosis associated with hyperventilation
ANS:A
Patients with ARDS often have hypoxemia refractory to treatment.
Incorrect:
B: Patients with ARDS often have hypoxemia refractory to treatment; surfactant levels are often diminished.
C: Patients with ARDS often have hypoxemia refractory to treatment; compliance decreases in ARDS.
D: Patients with ARDS often have hypoxemia refractory to treatment. In early ARDS, hyperventilation may occur
along with respiratory alkalosis.
DIF:Cognitive Level: AnalysisREF:Page 449
OBJ:Describe the pathophysiology of ARF.
TOP:Nursing Process Step: AssessmentMSC:NCLEX: Physiologic Integrity
3.You are assessing a patient who is admitted for an overdose of sedatives. Which of the following complications
would you suspect?
a.Hyperventilation and respiratory acidosisb.Hypoventilation and respiratory acidosisc.Hypoventilation and
respiratory alkalosisd.Respiratory acidosis and normal oxygen levels
ANS:B
Hypoventilation is common after overdose and results in impaired elimination of carbon dioxide and respiratory
acidosis.
Incorrect:
A: Hypoventilation is common after overdose and results in impaired elimination of carbon dioxide and
respiratory acidosis.
C: Hypoventilation is common after overdose and results in impaired elimination of carbon dioxide and respiratory
acidosis.
D: Hypoventilation is common after overdose and results in impaired elimination of carbon dioxide and
respiratory acidosis.
DIF:Cognitive Level: AnalysisREF:Page 439
OBJ:Describe the pathophysiology of ARF.
TOP:Nursing Process Step: AssessmentMSC:NCLEX: Physiologic Integrity
4.Intrapulmonary shunting refers to:
a.alveoli that are not perfused.b.blood that is shunted from the left side of the heart to the right and causes heart
failure.c.blood that is shunted from the right side of the heart to the left without oxygenation.d.shunting of blood
supply to only one lung.
ANS:C
Shunting refers to blood that is not oxygenated in the lungs.
Incorrect:
A: Shunting refers to blood that is not oxygenated in the lungs.
B: Shunting refers to blood that is not oxygenated in the lungs.
D: Shunting refers to blood that is not oxygenated in the lungs.
DIF:Cognitive Level: ComprehensionREF:Page 439
OBJ:Describe the pathophysiology of ARF.
TOP:Nursing Process Step: AssessmentMSC:NCLEX: Physiologic Integrity
5.When fluid is present in the alveoli:
a.alveoli collapse and atelectasis occurs.b.diffusion of oxygen and carbon dioxide is impaired.c.hypoventilation
occurs.d.the patient is in heart failure.
ANS:B
Fluid prevents the diffusion of gases.
Incorrect:
A: Fluid prevents the diffusion of gases.
C: Fluid prevents the diffusion of gases.
D: Fluid prevents the diffusion of gases.
DIF:Cognitive Level: ComprehensionREF:Page 440 | Figure 14-1
OBJ:Describe the pathophysiology of ARF.
TOP:Nursing Process Step: AssessmentMSC:NCLEX: Physiologic Integrity
6.Which of the following assessments indicates an early sign of hypoxemia?
a.Clubbing of nail bedsc.Hypotensionb.Cyanosisd.Restlessness
ANS:D
Central nervous system signs, such as restlessness, are early indications of low oxygen levels.
Incorrect:
A: Central nervous system signs, such as restlessness, are early indications of low oxygen levels. Clubbing is a
sign of chronic hypoxemia.
B: Central nervous system signs, such as restlessness, are early indications of low oxygen levels. Cyanosis is a late
sign of hypoxemia.
C: Central nervous system signs, such as restlessness, are early indications of low oxygen levels. Tachycardia and
increased blood pressure may be seen early in hypoxemia.
DIF:Cognitive Level: AnalysisREF:Page 441
OBJ:Describe methods for assessing the patient with ARF.
TOP:Nursing Process Step: AssessmentMSC:NCLEX: Physiologic Integrity
7.The basic underlying pathophysiology of acute respiratory distress syndrome results from:
a.a decrease in the number of white blood cells available.b.damage to the right mainstem bronchus.c.damage to the
type II pneumocytes, which produce surfactant.d.decreased capillary permeability.
ANS:C
Acute respiratory distress syndrome results in damage to the pneumocytes, increased capillary permeability, and
noncardiogenic pulmonary edema.
Incorrect:
A: Acute respiratory distress syndrome results in damage to the pneumocytes, increased capillary permeability,
and noncardiogenic pulmonary edema.
B: Acute respiratory distress syndrome results in damage to the pneumocytes, increased capillary permeability,
and noncardiogenic pulmonary edema.
D: Acute respiratory distress syndrome results in damage to the pneumocytes, increased capillary permeability,
and noncardiogenic pulmonary edema.
DIF:Cognitive Level: ComprehensionREF:Page 464
OBJ:Describe the pathophysiology of ARF.
TOP:Nursing Process Step: AssessmentMSC:NCLEX: Physiologic Integrity
8.Mr. Gonzales has ARDS. He is hypoxemic despite mechanical ventilation. The physician orders a nontraditional
ventilator mode as part of treatment. Despite sedation and analgesia, Mr. Gonzales is uncomfortable and restless.
Which of the following treatments may be indicated at this time to facilitate the nontraditional mode of
ventilation?
a.Continuous lateral rotation therapyc.Neuromuscular blockadeb.Guided imageryd.Prone positioning
ANS:C
Paralysis and additional sedation may be needed if the patient requires nontraditional ventilation.
Incorrect:
A: Paralysis and additional sedation may be needed if the patient requires nontraditional ventilation.
B: Paralysis and additional sedation may be needed if the patient requires nontraditional ventilation.
D: Paralysis and additional sedation may be needed if the patient requires nontraditional ventilation.
DIF:Cognitive Level: AnalysisREF:Page 452
OBJ:Discuss medical management of the patient with ARF.
TOP:Nursing Process Step: EvaluationMSC:NCLEX: Physiologic Integrity
9.If a patient with chronic obstructive pulmonary disease presents to the emergency department in ARF, which of
the following treatments might be indicated to facilitate ventilation?
a.Emergency tracheostomy and mechanical ventilationb.Mechanical ventilation via an endotracheal
tubec.Noninvasive positive pressure ventilation (NPPV)d.Oxygen at 100% via bag-valve mask device
ANS:C
Noninvasive measures are often recommended in the initial treatment of the patient with chronic obstructive
pulmonary disease to prevent intubation and ventilator dependence.
Incorrect:
A: Patients with ARF from an exacerbation of chronic obstructive pulmonary disease benefit from early treatment
with NPPV. Emergency tracheostomy is not indicated.
B: Patients with ARF from an exacerbation of chronic obstructive pulmonary disease benefit from early treatment
with NPPV. Endotracheal intubation is a later treatment when NPPV is ineffective.
D: Patients with ARF from an exacerbation of chronic obstructive pulmonary disease benefit from early treatment
with NPPV. Oxygen 100% via bag-valve mask device is not indicated.
DIF:Cognitive Level: AnalysisREF:Page 456
OBJ:Discuss medical management of the patient with ARF.
TOP:Nursing Process Step: PlanningMSC:NCLEX: Physiologic Integrity
10.Which of the following acid-base disturbances commonly occurs with the hyperventilation and impaired gas
exchange seen in severe exacerbation of asthma?
a.Metabolic acidosisc.Respiratory acidosisb.Metabolic alkalosisd.Respiratory alkalosis
ANS:C
Although the patient with a severe exacerbation of asthma hyperventilates, gas exchange is impaired, which causes
respiratory acidosis.
Incorrect:
A: Although the patient with a severe exacerbation of asthma hyperventilates, gas exchange is impaired, which
causes respiratory acidosis.
B: Although the patient with a severe exacerbation of asthma hyperventilates, gas exchange is impaired, which
causes respiratory acidosis.
D: Although the patient with a severe exacerbation of asthma hyperventilates, gas exchange is impaired, which
causes respiratory acidosis.
DIF:Cognitive Level: AnalysisREF:Page 456
OBJ:Describe the pathophysiology of ARF.
TOP:Nursing Process Step: AssessmentMSC:NCLEX: Physiologic Integrity
11.An acute exacerbation of asthma is treated with:
a.Corticosteroids and theophylline by mouthb.Inhaled bronchodilators and intravenous corticosteroidsc.Prone
positioning or continuous lateral rotationd.Sedation and inhaled bronchodilators
ANS:B
Inhaled bronchodilators and intravenous corticosteroids are standard treatment for the exacerbation of asthma; they
promote dilation of the bronchioles and decreased inflammation of the airways.
Incorrect:
A: Inhaled bronchodilators and intravenous corticosteroids are standard treatment for the exacerbation of asthma;
they promote dilation of the bronchioles and decreased inflammation of the airways.
C: Inhaled bronchodilators and intravenous corticosteroids are standard treatment for the exacerbation of asthma;
they promote dilation of the bronchioles and decreased inflammation of the airways.
D: Inhaled bronchodilators and intravenous corticosteroids are standard treatment for the exacerbation of asthma;
they promote dilation of the bronchioles and decreased inflammation of the airways.
DIF:Cognitive Level: AnalysisREF:Page 457
OBJ:Discuss medical management of the patient with ARF.
TOP:Nursing Process Step: Implementation
MSC:NCLEX: Physiologic Integrity
12.Which of the following positions would not be well tolerated in the patient with ARF?
a.High Fowler'sc.Sitting in a chairb.Side lying with head of bed elevatedd.Supine with the bed flat
ANS:D
Patients in respiratory distress are unable to tolerate a flat position.
Incorrect:
A: High Fowler’s is appropriate. Patients in respiratory distress are unable to tolerate a flat position.
B: Side lying with head of bed elevated is appropriate. Patients in respiratory distress are unable to tolerate a flat
position.
C: Sitting in a chair is appropriate. Patients in respiratory distress are unable to tolerate a flat position.
DIF:Cognitive Level: AnalysisREF:Page 444
OBJ:Formulate a plan of care for the patient with ARF.
TOP:Nursing Process Step: Implementation
MSC:NCLEX: Physiologic Integrity
13.Which of the following is an important nursing intervention for the patient with exacerbation of asthma before
discharge?
a.Follow-up pulmonary function studies 1 week after dischargeb.Giving instructions about limiting activity until
patient is able to climb two flights of stairsc.Giving instructions about proper use of medications for the
asthmad.Giving instructions about taking all medications on a “prn” basis according to symptoms
ANS:C
Exacerbation of asthma is often related to not adhering to the therapeutic regimen; patient teaching is essential.
Incorrect:
A: Exacerbation of asthma is often related to not adhering to the therapeutic regimen; patient teaching is essential.
Follow-up studies will be determined by the physician.
B: Exacerbation of asthma is often related to not adhering to the therapeutic regimen; patient teaching is essential.
Activity is based on the patient’s activity tolerance and is not limited.
D: Exacerbation of asthma is often related to not adhering to the therapeutic regimen; patient teaching is essential.
Medications are taken regularly to avoid exacerbation.
DIF:Cognitive Level: AnalysisREF:Page 458
OBJ:Formulate a plan of care for the patient with ARF.
TOP:Nursing Process Step: Implementation
MSC:NCLEX: Physiologic Integrity
14.Which of the following is NOT a strategy for preventing ventilator-associated pneumonia?
a.Aseptic technique during suctioningb.Elevating the head of the bedc.Maintaining adequate pressure in the cuff of
the endotracheal tubed.Routine administration of antibiotics to all intensive care unit patients who are intubated
ANS:D
Antibiotics should only be used as needed to prevent resistance, which is a common problem in critically ill
patients.
Incorrect:
A: Aseptic technique during suctioning is an appropriate intervention.
B: Elevating the head of the bed is an appropriate intervention.
C: Maintaining adequate pressure in the cuff of the endotracheal tube is an appropriate intervention.
DIF:Cognitive Level: AnalysisREF:Page 461
OBJ:Formulate a plan of care for the patient with ARF.
TOP:Nursing Process Step: Implementation
MSC:NCLEX: Physiologic Integrity
15.Which of the following routine assessments will help in the detection of deep vein thrombosis (DVT)?
a.Assessing for Homans' signc.Measurement of girth of thighb.Auscultation of lung soundsd.Measuring peripheral
pulses in feet
ANS:A
A positive Homans' sign is a classic sign of DVT; however, it only occurs in about 50% of cases.
Incorrect:
B: Auscultation of lung sounds does not assist in assessment of DVT.
C: Measurement of the calf girth, not the thigh, is one way to assist in assessment for DVT.
D: Assessment of peripheral pulses is a routine nursing intervention; however, it does not assist in recognizing
DVT.
DIF:Cognitive Level: ComprehensionREF:Page 465
OBJ:Describe methods for assessing the patient with ARF.
TOP:Nursing Process Step: AssessmentMSC:NCLEX: Physiologic Integrity
16.Maintaining adequate pressure in the endotracheal tube cuff helps to reduce:
a.aspiration of secretions and ventilator-associated pneumonia.b.high-pressure alarms on the ventilator.c.patient
discomfort associated with mechanical ventilation.d.self-extubation of intubated patients.
ANS:A
Adequate cuff pressure helps prevent aspiration of secretions that accumulate above the endotracheal tube cuff.
Incorrect:
B: Adequate cuff pressure helps prevent aspiration of secretions that accumulate above the endotracheal tube cuff.
C: Adequate cuff pressure helps prevent aspiration of secretions that accumulate above the endotracheal tube cuff.
D: Adequate cuff pressure helps prevent aspiration of secretions that accumulate above the endotracheal tube cuff.
DIF:Cognitive Level: AnalysisREF:Page 461
OBJ:Formulate a plan of care for the patient with ARF.
TOP:Nursing Process Step: Implementation
MSC:NCLEX: Physiologic Integrity
17.Which of the following statements is true regarding venous thromboembolism (VTE) and pulmonary embolus
(PE)?
a.PE should be suspected in any patient who has unexplained cardiorespiratory complaints and risk factors for
VTE.b.Bradycardia and hyperventilation are classic symptoms of PE.c.Dyspnea, chest pain, and hemoptysis occur
in nearly all patients with PE.d.Most critically ill patients are at low risk for VTE and PE and do not require
prophylaxis.
ANS:A
PE should be suspected in any patient who has unexplained cardiorespiratory complaints and risk factors for VTE.
Incorrect:
B: Bradycardia and hyperventilation are not classic signs of PE. Dyspnea, hemoptysis, and chest pain have been
called the "classic" signs and symptoms for PE.
C: PE should be suspected in any patient who has unexplained cardiorespiratory complaints and risk factors for
VTE. Dyspnea, hemoptysis, and chest pain have been called the "classic" signs and symptoms for PE, but the three
signs and symptoms actually occur in less than 20% of cases.
D: PE should be suspected in any patient who has unexplained cardiorespiratory complaints and risk factors for
VTE. Most critically ill patients are at high risk for VTE and all should receive prophylaxis.
DIF:Cognitive Level: AnalysisREF:Page 464
OBJ:Discuss medical management of the patient with ARF.
TOP:Nursing Process Step: AssessmentMSC:NCLEX: Physiologic Integrity
18.Which of the following is NOT a classic treatment for the patient with cystic fibrosis (CF)?
a.Airway clearance therapiesc.Nutritional supportb.Antibiotic therapyd.Tracheostomy
ANS:D
The three cornerstones of care for a patient with CF are antibiotic therapy, airway clearance, and nutritional
support. A tracheostomy is not a standard treatment for CF.
Incorrect:
A: The three cornerstones of care for a patient with CF are antibiotic therapy, airway clearance, and nutritional
support.
B: The three cornerstones of care for a patient with CF are antibiotic therapy, airway clearance, and nutritional
support.
C: The three cornerstones of care for a patient with CF are antibiotic therapy, airway clearance, and nutritional
support.
DIF:Cognitive Level: AnalysisREF:Page 470
OBJ:Discuss medical management of the patient with ARF.
TOP:Nursing Process Step: Implementation
MSC:NCLEX: Physiologic Integrity
19.A definitive diagnosis of pulmonary embolism can be made by:
a.arterial blood gas (ABG) analysis.c.pulmonary angiogram.b.chest x-ray examination.d.ventilation-perfusion
scanning.
ANS:C
The angiogram is the only test that can confirm pulmonary embolism.
Incorrect:
A: A pulmonary angiogram is considered the gold standard for detecting a PE. ABG would only indicate
hypoxemia and/or acid-base abnormalities.
B: A pulmonary angiogram is considered the gold standard for detecting a PE. A chest x-ray study is
nonconclusive.
D: A pulmonary angiogram is considered the gold standard for detecting a PE. A ventilation-perfusion scan is
nonconclusive.
DIF:Cognitive Level: AnalysisREF:Page 465
OBJ:Discuss medical management of the patient with ARF.
TOP:Nursing Process Step: AssessmentMSC:NCLEX: Physiologic Integrity
20.A strategy for preventing thromboembolism in patients at risk who cannot take anticoagulants is:
a.administration of two aspirin tablets every 4 hours.b.infusion of thrombolytics.c.insertion of a vena cava
filter.d.subcutaneous heparin administration every 12 hours.
ANS:C
A filter may be inserted as a prevention measure in patients who are at high risk for thromboembolism.
Incorrect:
A: A filter may be inserted as a prevention measure in patients who are at high risk for thromboembolism. Aspirin
is not a preventive therapy.
B: A filter may be inserted as a prevention measure in patients who are at high risk for thromboembolism.
Thrombolytics are given to treat, not prevent, pulmonary embolism.
D: A filter may be inserted as a prevention measure in patients who are at high risk for thromboembolism. Heparin
is administered as a prophylaxis in acute care settings. Coumadin is given for long-term prevention in patients at
high risk for VTE.
DIF:Cognitive Level: AnalysisREF:Page 466
OBJ:Discuss medical management of the patient with ARF.
TOP:Nursing Process Step: Implementation
MSC:NCLEX: Physiologic Integrity
21.Which of the following treatments may be used to dissolve a thrombus that is lodged in the pulmonary artery?
a.Aspirinc.Heparinb.Embolectomyd.Thrombolytics
ANS:D
Thrombolytics are also useful in the management of pulmonary embolus. Heparin will prevent further clot
formation, but it will not dissolve the clot.
Incorrect:
A: Thrombolytics are useful in the management of pulmonary embolus. Aspirin is not a thrombolytic agent.
B: An embolectomy is a surgical procedure to remove the clot. Thrombolytics are given to dissolve a clot.
C: Heparin will prevent further clot formation, but it will not dissolve the clot. Thrombolytics are given to dissolve
a clot.
DIF:Cognitive Level: AnalysisREF:Page 466
OBJ:Discuss medical management of the patient with ARF.
TOP:Nursing Process Step: Implementation
MSC:NCLEX: Physiologic Integrity
22.Which of the following indicate development of ARDS?
a.Increased oxygen saturation via pulse oximetryb.Increased peak inspiratory pressure on the ventilatorc.Normal
chest radiograph with enlarged cardiac structuresd.PaO2/FIO2 ratio > 300
ANS:B
Increased peak inspiratory pressures are often early indicators of ARDS.
Incorrect:
A: Increased peak inspiratory pressures are often early indicators of ARDS. Oxygen saturation decreases.
C: Increased peak inspiratory pressures are often early indicators of ARDS. Chest x-ray study will show
progressive infiltrates.
D: Increased peak inspiratory pressures are often early indicators of ARDS. The PaO2/FIO2 is less than 200.
DIF:Cognitive Level: AnalysisREF:Page 448 | Table 14-1
OBJ:Describe methods for assessing the patient with ARF.
TOP:Nursing Process Step: AssessmentMSC:NCLEX: Physiologic Integrity
23.Calculate the PaO2/FIO2 ratio for the following values: PaO2 is 78; FIO2 is .60 (60%).
a.46.8; meets criteria for ARDSc.468; normal lung functionb.130; meets criteria for ARDSd.Not enough data to
compute the ratio
ANS:B
78/.60 = 130, which meets the criteria for ARDS.
Incorrect:
A: 78/.60 = 130, which meets the criteria for ARDS.
C: 78/.60 = 130, which meets the criteria for ARDS.
D: 78/.60 = 130, which meets the criteria for ARDS.
DIF:Cognitive Level: SynthesisREF:Page 448 | Table 14-1
OBJ:Describe methods for assessing the patient with ARF.
TOP:Nursing Process Step: AssessmentMSC:NCLEX: Physiologic Integrity
24.You would expect the patient with ARDS to have which of the following?
a.Cardiac output of 10 L/min and low systemic vascular resistanceb.PAOP of 10 mm Hg and PaO2 of 55c.PAOP
of 20 mm Hg and cardiac output of 3 L/mind.PAOP of 5 mm Hg and high systemic vascular resistance
ANS:B
A normal PAOP with hypoxemia is an expected assessment finding in ARDS
Incorrect:
A: Cardiac output of 10 L/min and low systemic vascular resistance are expected findings in sepsis.
C: PAOP of 20 mm Hg and cardiac output of 3 L/min are expected findings in heart failure.
D: PAOP of 5 mm Hg and high systemic vascular resistance are expected findings in hypovolemic shock.
DIF:Cognitive Level: SynthesisREF:Page 448 | Table 14-1
OBJ:Describe methods for assessing the patient with ARF.
TOP:Nursing Process Step: AssessmentMSC:NCLEX: Physiologic Integrity
25.Which of the following would be the HIGHEST priority nursing concern if prone positioning is ordered to treat
the patient with ARDS?
a.Management and protection of the airwayb.Prevention of gastric aspirationc.Prevention of skin breakdown and
nerve damaged.Psychological support to patient and family
ANS:A
All are important, but protection of the airway is the most important intervention if the patient is placed in the
prone position.
Incorrect:
B: All are important, but protection of the airway is the most important intervention if the patient is placed in the
prone position.
C: All are important, but protection of the airway is the most important intervention if the patient is placed in the
prone position.
D: All are important, but protection of the airway is the most important intervention if the patient is placed in the
prone position.
DIF:Cognitive Level: AnalysisREF:Page 448 | Table 14-1
OBJ:Describe the pathophysiology of ARF.
TOP:Nursing Process Step: AssessmentMSC:NCLEX: Physiologic Integrity
MULTIPLE RESPONSE
1.Identify diagnostic criteria for ARDS (choose all that apply).
a.Bilateral infiltrates on chest x-ray studyb.Decreased cardiac outputc.PaO2/ FIO2 ratio of less than
200d.Pulmonary artery occlusion pressure (PAOP) of more than 18 mm Hg
ANS:A, C
Diagnostic criteria for ARDS include bilateral infiltrates, or “white out,” on chest x-ray study and a low PaO2/
FIO2 ratio. Decreased cardiac output and a high PAOP are seen in pulmonary edema associated with cardiac
causes.
Incorrect:
B: Diagnostic criteria for ARDS include bilateral infiltrates, or “white out,” on chest x-ray study and a low PaO2/
FIO2 ratio. Decreased cardiac output and a high PAOP are seen in pulmonary edema associated with cardiac
causes.
D: Diagnostic criteria for ARDS include bilateral infiltrates, or “white out,” on chest x-ray study and a low PaO2/
FIO2 ratio. Decreased cardiac output and a high POAP are seen in pulmonary edema associated with cardiac
causes.
DIF:Cognitive Level: AnalysisREF:Page 462
OBJ:Formulate a plan of care for the patient with ARF.
TOP:Nursing Process Step: Implementation
MSC:NCLEX: Physiologic Integrity
2.Which of the following statements is true regarding oral care for the prevention of ventilator associated
pneumonia (VAP) (choose all that apply)?
a.If done, tooth brushing is performed every 2 hours for the greatest effect.b.Implementing a comprehensive oral
care program is an intervention for preventing VAP.c.Oral care protocols should include oral suctioning and
brushing teeth.d.Protocols that include chlorhexidine gluconate have been effective in preventing VAP in cardiac
surgery patients.
ANS:B, C, D
A comprehensive oral care protocol is an intervention for preventing VAP. It includes oral suction, brushing teeth
every 12 hours, and swabbing. Chlorhexidine gluconate has been effective in cardiac surgery patients.
Incorrect:
A: A comprehensive oral care protocol is an intervention for preventing VAP. It includes oral suction, brushing
teeth every 12 hours, and swabbing. Chlorhexidine gluconate has been effective in cardiac surgery patients.
DIF:Cognitive Level: SynthesisREF:Page 452
OBJ:Formulate a plan of care for the patient with ARF.
TOP:Nursing Process Step: PlanningMSC:NCLEX: Physiologic Integrity
3.Which of the following are physiological effects of positive end-expiratory pressure (PEEP) used in the
treatment of ARDS (choose all that apply)?
a.Increase functional residual capacityc.Improve arterial oxygenationb.Prevent collapse of unstable alveolid.Open
collapsed alveoli
ANS:A, B, C, D
Ventilatory support for ARDS typically includes PEEP to restore functional residual capacity, open collapsed
alveoli, prevent collapse of unstable alveoli, and improve arterial oxygenation.
DIF:Cognitive Level: AnalysisREF:Page 451
OBJ:Discuss medical management of the patient with ARF.
TOP:Nursing Process Step: Implementation
MSC:NCLEX: Physiologic Integrity
4.Which of the following are components of the Institution of Healthcare Improvement’s (IHI's) ventilator bundle
(choose all that apply)?
a.Interrupt sedation each day to assess readiness to extubate.b.Maintain head of bed at least 30 degrees
elevation.c.Provide deep vein thrombosis prophylaxis.d.Provide prophylaxis for peptic ulcer disease.e.Swab the
mouth with foam swabs every 2 hours.
ANS:A, B, C, D
Options A, B, C, and D are components of the IHI ventilator bundle. Oral care is not yet an official part of the
bundle. When included, oral care consists of suction, brushing, and swabbing. Swabbing alone provides comfort
care.
Incorrect:
E: Oral care is not yet an official part of the bundle. When included, oral care consists of suction, brushing, and
swabbing. Swabbing alone provides comfort care.
DIF:Cognitive Level: AnalysisREF:Page 461 | Box 14-4
OBJ:Formulate a plan of care for the patient with ARF.
TOP:Nursing Process Step: Implementation
MSC:NCLEX: Physiologic Integrity
5.Select the strategies for preventing DVT and PE (choose all that apply).
a.Application of antiembolic hoseb.Heparin or low-molecular-weight heparin for patients at riskc.Sequential
compression devicesd.Strict bed rest
ANS:A, B, C
Antiembolic stockings, sequential compression devices, and anticoagulation can reduce the risk for DVT. Physical
activity can also reduce the risk; bed rest increases the risk.
Incorrect:
D: Antiembolic stockings, sequential compression devices, and anticoagulation can reduce the risk for DVT.
Physical activity can also reduce the risk; bed rest increases the risk.
DIF:Cognitive Level: AnalysisREF:Page 466 | Box 14-7
OBJ:Formulate a plan of care for the patient with ARF.
TOP:Nursing Process Step: AssessmentMSC:NCLEX: Physiologic Integrity
COMPLETION
1.The etiology of PE in ARDS is related to damage to the ____________________ membrane.
ANS:alveolar-capillary
Damage to the alveolar-capillary membrane results in noncardiogenic PE.
DIF:Cognitive Level: ComprehensionREF:Page 449
OBJ:Describe the pathophysiology of ARF.
TOP:Nursing Process Step: AssessmentMSC:NCLEX: Physiologic Integrity
2.On the following picture of the alveolar-capillary membrane, select the image that demonstrates shunting.
shapeType75fFlipH0fFlipV0pibFlags2fLine0fLayoutInCell1fLayoutInCell1
shapeType75fFlipH0fFlipV0pibFlags2fLine0fLayoutInCell1fLayoutInCell1
shapeType75fFlipH0fFlipV0pibFlags2fLine0fLayoutInCell1fLayoutInCell1
shapeType75fFlipH0fFlipV0pibFlags2fLine0fLayoutInCell1fLayoutInCell1
shapeType75fFlipH0fFlipV0pibFlags2fLine0fLayoutInCell1fLayoutInCell1
ANS:C
Figure C shows a shunt.
Incorrect:
A: normal alveolar-capillary unit
B: Hypoventilation with increased PaCO2 and decreased PaO2
D: ventilation/perfusion mismatch
E: diffusion defect
DIF:Cognitive Level: SynthesisREF:Page 440 | Figure 14-1
OBJ:Describe the pathophysiology of ARF.TOP:Nursing Process Step: n/a
MSC:NCLEX: Physiologic Integrity
