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Walden University *

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MISC

Subject

Nursing

Date

Nov 24, 2024

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pdf

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1

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Chapter 15: Acute Respiratory Failure Sole: Introduction to Critical Care Nursing, 8th Edition MULTIPLE CHOICE 1. The nurse caring for a patient diagnosed with acute respiratory failure identifies “Risk for Ineffective Airway Clearance” as a nursing diagnosis. What nursing intervention is relevant to this diagnosis? a. Elevate head of bed to 30 degrees. b. Obtain order for venous thromboembolism prophylaxis. c. Provide adequate sedation. d. Reposition patient every 2 hours. ANS: D Repositioning the patient will facilitate mobilization of secretions. Elevating the head of bed is an intervention to prevent infection. Venous thromboembolism prophylaxis is ordered to prevent complications of immobility. Sedation is an intervention to manage anxiety, and administration of sedatives increases the risk for retained secretions. DIF: Cognitive Level: Analysis OBJ: Formulate a plan of care for the patient with ARF. TOP: Nursing Process Step: Intervention MSC: NCLEX: Physiological Integrity 2. The patient diagnosed with acute respiratory distress syndrome (ARDS) would exhibit which symptom? a. Decreasing PaO 2 levels despite increased FiO 2 administration b. Elevated alveolar surfactant levels c. Increased lung compliance with increased FiO 2 administration d. Respiratory acidosis associated with hyperventilation ANS: A Patients with ARDS often have hypoxemia refractory to treatment. Surfactant levels are often diminished in ARDS. Compliance decreases in ARDS. In early ARDS, hyperventilation may occur along with respiratory alkalosis.
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