Respiratory Disorder/ARDS Review

An accumulation of tissue fluid in the alveoli of the lungs:

• pulmonary edema

• pneumonia

• pleural effusion

• pulmonary thromboembolism

Interpret the following ABG: pH 7.48, Pa02 56, PaC02 30, HC03 25, Fi02 45

• uncompensated respiratory alkalosis

• uncompensated metabolic acidosis

• uncompensated respiratory acidosis

• compensated respiratory acidosis

What is the primary goal for a patient with ARDS?

• increase respiratory rate

• achieve adequate oxygenation

• volume control

• keep C02 within normal range

Where do pulmonary emboli most commonly originate?

• upper extremities

• brain

• heart

• lower extremities

Interpret the following ABG: pH 7.34, Pa02 90, PaC02 70, HC03 36, Fi02 45

• compensated respiratory alkalosis

• uncompensated respiratory alkalosis

• compensated respiratory acidosis

• partially compensated respiratory acidosis

What interventions would promote the clearing of pulmonary secretions? (SELECT ALL THAT APPLY)

• Use of incentive spirometer

• Supine positioning

• Chest physiotherapy

• Encouraging coughing and deep breathing

• Fluid Restriction

AB experiences a sudden hypoxic episode when ambulating. His O2sat drops to 82% on 2 L NC and his respiratory rate increases to 40 bpm.

During the hypoxic episode, what would be the priority nursing intervention?

• Administer pain medication and call the pharmacist.

• Start another IV and call the nurse manager.

• Administer additional oxygen via a non-rebreather mask and call the physician.

• Reassure the patient and family.

When admitting a patient in possible respiratory failure with a high PaCO2, which assessment information will be of most concern to the nurse?

• The patient is somnolent

• The patient's SpO2 is 90%

• The patient complains of weakness

• The patient's blood pressure is 162/94

The nurse obtains the vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature 101.2° F, blood pressure 90/56 mm Hg, pulse 92, respirations 34. Which action should the nurse take next?

• Administer the scheduled IV antibiotic.

• Give the PRN acetaminophen (Tylenol) 650 mg.

• Obtain oxygen saturation using pulse oximetry.

• Notify the health care provider of the patient's vital signs.

When assessing a patient with chronic lung disease, the nurse finds a sudden onset of agitation and confusion. Which action should the nurse take first?

• Check pupil reaction to light.

• Notify the health care provider.

• Attempt to calm and reassure the patient.

• Assess oxygenation using pulse oximetry.