Chapter 68 Nursing Management Respiratory Failure And Acute
Chapter 68: Nursing Management: Respiratory Failure and Acute Respiratory Distress
Syndrome
Test Bank
MULTIPLE CHOICE
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
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 patient’s ventilatory failure.
DIF: Cognitive Level: Apply (application)
REF:
1661
TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
2. While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes
a change in the patient’s oxygen saturation (SpO2) from 94% to 88%. Which action should the nurse take next?
a. Increase the oxygen flow rate.
b. Suction the patient’s oropharynx.
c. Instruct the patient to cough and deep breathe.
d. Help the patient to sit in a more upright position.
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.
DIF: Cognitive Level: Apply (application)
REF:
1656
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
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.
Syndrome
Test Bank
MULTIPLE CHOICE
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
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 patient’s ventilatory failure.
DIF: Cognitive Level: Apply (application)
REF:
1661
TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
2. While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes
a change in the patient’s oxygen saturation (SpO2) from 94% to 88%. Which action should the nurse take next?
a. Increase the oxygen flow rate.
b. Suction the patient’s oropharynx.
c. Instruct the patient to cough and deep breathe.
d. Help the patient to sit in a more upright position.
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.
DIF: Cognitive Level: Apply (application)
REF:
1656
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
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.