Chapter 67 Acute Respiratory Failure and Acute Respiratory Distress Syndrome

A student nurse is caring for a patient who has Guillen-Barré syndrome. The nurse reminds the student to check which laboratory value that, if abnormal, can suggest the ventilatory compromise seen in acute respiratory failure (ARF)?

Partial pressure of carbon dioxide in arterial blood (PaCO2)

The adult health nurse is assessing a patient admitted with acute respiratory failure (ARF). Which information is most important to obtain from the patient’s history?

-Diagnosed with asthma at age 9
-Smokes 2 packs of cigarettes a day for the last 12 years

The nurse is assessing a patient with dyspnea who has asthma. The nurse will recognize that this patient may be beginning to experience type II acute respiratory failure (ARF) if which finding is noted?

Respiratory rate of 24 breaths/min and a PaCO2 of 48 mm Hg

A patient with bilateral pneumonia presents with crackles in both lung bases, a temperature of 103.6° F, heart rate of 98 beats/min, blood pressure of 167/98 mm Hg, functional oxygen saturation of 84%, and respiratory rate of 32 breath/min.Which action would the nurse take first?

Apply oxygen.

The nurse is caring for a patient with metastatic lung cancer and worsening anxiety. The nurse notes that the patient has become increasingly restless. The nurse anticipates which order form the health care provider?

Oxygen via nasal cannula at 3 L/min

A new nurse is caring for a patient with acute respiratory failure (ARF). Which action by the new nurse, if noted by the registered nurse, indicates a need for further teaching?

The new nurse encourages the patient to maintain a low-protein, high-calorie diet.

The nurse is caring for several patients. Which patient’s vital signs and diagnostic information indicate the need for immediate evaluation by the nurse?

A 28-year-old patient with cystic fibrosis experiencing dizziness, restlessness, and fatigue whose arterial blood gas values indicate a decreased pH of 7.30.

A patient using pursed-lip breathing with a rapid, shallow breathing pattern is lying down and complaining of the inability to breathe. Which action would the nurse take first?

Reposition patient.

The nurse is caring for a female patient with acute respiratory failure (ARF). The nurse can hear audible crackles, and when the nurse instructs the patient to cough, the patient states, “I’m too weak to do it.” Which action should the nurse take?

Push both hands into the patient’s abdomen during expiration to facilitate a cough.