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Chapter 29: Critical Care of Patients With Respiratory Emergencies
Ignatavicius: Medical-Surgicalabirb.com/test
Nursing, 10th Edition

MULTIPLE CHOICE abirb.com/test

1. A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain,
and has a blood pressure of 88/52 mm Hg. What action by the nurse takes priority?
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a. Assess the client’s lung sounds.
b. Notify the Rapid Response Team.
c. Provide reassurance to the client.
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d. Take a full set of vital signs.
ANS: B
This client has signs and symptoms of a pulmonary embolism, and the most critical action is
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to notify the Rapid Response Team for speedy diagnosis and treatment. The other actions are
appropriate also but are not the priority.

DIF: Remembering
TOP: abirb.com/test
Integrated Process: Communication and Documentation
KEY: Pulmonary embolism, Critical rescue
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

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2. A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active
and has no known risk factors for PE. What action by the nurse is most appropriate?
a. Encourage the client to walk 5 minutes each hour.
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b. Refer the client to smoking cessation classes.
c. Teach the client about factor V Leiden testing.
d. Tell the client that sometimes no cause for disease is found.
ANS: C abirb.com/test
Factor V Leiden is an inherited thrombophilia that can lead to abnormal clotting events,
including PE. A client with no known risk factors for this disorder would be asked about
family history and referred for testing. Encouraging the client to walk is healthy, but is not
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related to the development of a PE in this case, nor is smoking. Although there are cases of
disease where no cause is ever found, this assumption is premature.

DIF: Applying abirb.com/test

TOP: Integrated Process: Teaching/Learning
KEY: Pulmonary embolism, Genetic testing
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

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3. A client has a large pulmonary embolism and is started on oxygen. The nurse asks the charge
nurse why the client’s oxygen saturation has not significantly improved. What response by the
nurse is best?
a. “Breathing so rapidly interferes with oxygenation.”
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b. “Maybe the client has respiratory distress syndrome.”
c. “The blood clot interferes with perfusion in the lungs.”
d. “The client needs immediate intubation and mechanical ventilation.”
ANS: C
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A large blood clot in the lungs will significantly impair gas exchange and oxygenation. Unless
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the clot is dissolved, this process will continue unabated. Hyperventilation can interfere with
oxygenation by shallow breathing, but there is no evidence that the client is hyperventilating,
and this is also not the most precise physiologic answer. Acute respiratory distress syndrome
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can occur, but this is not as likely soon after the client starts on oxygen plus there is no
indication of how much oxygen the client is on. The client may need to be mechanically
ventilated, but without concrete data on FiO2 and SaO2, the nurse cannot make that judgment.

DIF: Applying abirb.com/test

TOP: Integrated Process: Teaching/Learning
KEY: Pulmonary embolism, Respiratory system
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

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4. A client is on intravenous heparin to treat a pulmonary embolism. The client’s most recent
partial thromboplastin time (PTT) was 25 seconds. What order would the nurse anticipate?
a. Decrease the heparin rate.
b. Increase the heparin rate. abirb.com/test
c. No change to the heparin rate.
d. Stop heparin; start warfarin.
ANS: B abirb.com/test
For clients on heparin, a PTT of 1.5 to 2.5 times the normal value is needed to demonstrate
that the heparin is working. A normal PTT is 25 to 35 seconds, so this client’s PTT value is
too low. The heparin rate needs to be increased. Warfarin is not indicated in this situation.
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DIF: Applying TOP: Integrated Process: Nursing Process: Analysis
KEY: Pulmonary embolism, Anticoagulants, Laboratory values
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MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

5. A client is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic
testing reveals that the client has an alteration in the gene CYP2C19. What action by the nurse
is best? abirb.com/test
a. Instruct the client to eliminate all vitamin K from the diet.
b. Prepare preoperative teaching for an inferior vena cava (IVC) filter.
c. Refer the client to a chronic illness support group.
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d. Teach the client to use a soft-bristled toothbrush.
ANS: B
Often clients are discharged from the hospital on warfarin after a PE. However, clients with a
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variation in the CYP2C19 gene do not metabolize warfarin well and have much higher blood
levels and more side effects. This client is a poor candidate for warfarin therapy, and the
prescriber will most likely order an IVC filter device to be implanted. The other option is to
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lower the dose of warfarin. The nurse would prepare to do preoperative teaching on this
procedure. It would be impossible to eliminate all vitamin K from the diet. A chronic illness
support group may be needed, but this is not the best intervention as it is not as specific to the
client as the IVC filter. A soft-bristled toothbrush is a safety measure for clients on
anticoagulation therapy.
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DIF: Applying TOP: Integrated Process: Nursing Process: Analysis
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KEY: Pulmonary embolism, Genetic alterations
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

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6. A nurse is caring for four clients on intravenous heparin therapy. Which laboratory value
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possibly indicates that a serious side effect has occurred?
a. Hemoglobin: 14.2 g/dL (142 g/L)
b. Platelet count: 82,000/L (82 × 109/L)
c. Red blood cell count: 4.8/mm3 (4.8 × 1012/L)
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d. White blood cell count: 8700/mm3 (8.7 × 109/L)

ANS: B
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This platelet count is low and could indicate heparin-induced thrombocytopenia. The other
values are normal for either gender.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment

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KEY: Anticoagulants, Laboratory values
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

7. A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best?
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a. Assess for other signs of hypoxia.
b. Change the sensor on the pulse oximeter.
c. Obtain a new oximeter from central supply.
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d. Tell the client to take slow, deep breaths.
ANS: A
Pulse oximetry is not always the most accurate assessment tool for hypoxia as many factors
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can interfere, producing normal or near-normal readings in the setting of hypoxia. The nurse
would conduct a more thorough assessment. The other actions are not appropriate for a
hypoxic client.

DIF: Applying abirb.com/test

TOP: Integrated Process: Nursing Process: Assessment
KEY: Respiratory assessment, Hypoxia
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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8. A nurse is assisting the primary health care provider (PHCP) who is intubating a client. The
PHCP has been attempting to intubate for 40 seconds. What action by the nurse is best?
a. Ensure that the client has adequate sedation.
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b. Find another qualified provider to intubate.
c. Interrupt the procedure to give oxygen.
d. Monitor the client’s oxygen saturation.
ANS: C abirb.com/test
Each intubation attempt should not exceed 30 seconds (15 is preferable) as it causes hypoxia.
The nurse would interrupt the intubation attempt and give the client oxygen. The nurse would
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also have adequate sedation during the procedure and monitor the client’s oxygen saturation,
but these do not take priority. Finding another qualified provider to intubate the client is not
appropriate at this time.

DIF: Applying abirb.com/test

TOP: Integrated Process: Nursing Process: Implementation
KEY: Respiratory system, Intubation
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
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9. An intubated client’s oxygen saturation has dropped to 88%. What action by the nurse takes
priority?
a. Determine if the tube is kinked.
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b. Ensure that all connections are patent.
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c. Listen to the client’s lung sounds.
d. Suction the endotracheal tube.
ANS: C
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When an intubated client shows signs of hypoxia, check for DOPE: displaced tube (most
common cause), obstruction (often by secretions), pneumothorax, and equipment problems.
The nurse listens for equal, bilateral breath sounds first to determine if the endotracheal tube
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is still correctly placed. If this assessment is normal, the nurse would follow the mnemonic
and perform suction if needed, assess for pneumothorax, and finally check the equipment.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment

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KEY: Mechanical ventilation, Respiratory assessment
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care

10. A client with acute respiratory failure is on a ventilator and is sedated. What care may the
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nurse delegate to the assistive personnel AP)?
a. Assess the client for sedation needs.
b. Get family permission for restraints.
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c. Provide frequent oral care per protocol.
d. Use nonverbal pain assessment tools.
ANS: C
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The client on mechanical ventilation needs frequent oral care, which can be delegated to the
AP. The other actions fall within the scope of practice of the nurse.

DIF: Applying TOP: Integrated Process: Communication and Documentation

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KEY: Mechanical ventilation, Oral care, Delegation
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care

11. A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator
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settings with the respiratory therapist, what would the nurse ensure?
a. The client is able to initiate spontaneous breaths.
b. The inspired oxygen has adequate humidification.
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c. The upper peak airway pressure limit alarm is off.
d. The upper peak airway pressure limit alarm is on.
ANS: D
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The upper peak airway pressure limit alarm will sound when the airway pressure reaches a
preset maximum. This is critical to prevent barotrauma to the lungs. Alarms are never be
turned off. Initiating spontaneous breathing is important for some modes of ventilation but not
others. Adequate humidification is important but does not take priority over preventing injury.
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DIF: Applying TOP: Integrated Process: Nursing Process: Implementation
KEY: Mechanical ventilation, Equipment safety
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MSC: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

12. A nurse is caring for a client on mechanical ventilation and finds the client agitated and
thrashing about. What action by the nurse is most appropriate?
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a. Assess the cause of the agitation.
b. Reassure the client that he or she is safe.
c. Restrain the client’s hands.
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d. Sedate the client immediately.
ANS: A
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The nurse needs to determine the cause of the agitation. The inability to communicate often
makes clients anxious, even to the point of panic. Pain, confusion, and hypoxia can also cause
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agitation. Once the nurse determines the cause of the agitation, he or she can implement
measures to relieve the underlying cause. Reassurance is also important but may not address
the etiology of the agitation. Restraints and more sedation may be necessary but not as a first
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step. Ensuring the client is adequately oxygenated is the priority.

DIF: Applying TOP: Integrated Process: Nursing Process: Assessment

KEY: Mechanical ventilation, Anxiety
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MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

13. A nurse is preparing to admit a client on mechanical ventilation for acute respiratory failure
from the emergency department. What action does the nurse take first?
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a. Assessing that the ventilator settings are correct
b. Ensuring that there is a bag-valve-mask in the room
c. Obtaining personal protective equipment
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d. Planning to suction the client upon arrival to the room
ANS: B
Having a bag-valve-mask device is critical in case the client needs manual breathing. The
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respiratory therapist is usually primarily responsible for setting up the ventilator, although the
nurse would know and check the settings. Personal protective equipment is important, but
ensuring client safety is the most important action. The client may or may not need suctioning
on arrival.
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DIF: Applying TOP: Integrated Process: Nursing Process: Implementation
KEY: Mechanical ventilation, Client safety
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MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care

14. A client is on mechanical ventilation and the client’s spouse wonders why ranitidine is needed
since the client “only has lung problems.” What response by the nurse is best?
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a. “It will increase the motility of the gastrointestinal tract.”
b. “It will keep the gastrointestinal tract functioning normally.”
c. “It will prepare the gastrointestinal tract for enteral feedings.”
d. “It will prevent ulcers from the stress of mechanical ventilation.”
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ANS: D
Stress ulcers can occur in many clients who are receiving mechanical ventilation, and often
prophylactic medications are used to prevent them and possible subsequent aspiration.
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Frequently used medications include antacids, histamine blockers, and proton pump
inhibitors. Ranitidine is a histamine-blocking agent.

DIF: Understanding abirb.com/test

TOP: Integrated Process: Teaching/Learning
KEY: Mechanical ventilation, Histamine blocker
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

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15. A client has been brought to the emergency department with a life-threatening chest injury.
What action by the nurse takes priority?
a. Apply oxygen at 100%.
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b. Assess the respiratory rate.
c. Ensure a patent airway. abirb.com/test
d. Start two large-bore IV lines.
ANS: C
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The priority for any chest trauma client is airway, breathing, and circulation. The nurse first
ensures that the client has a patent airway. Assessing respiratory rate and applying oxygen are
next, followed by inserting IVs.

DIF: Remembering
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TOP: Integrated Process: Nursing Process: Assessment
KEY: Emergency nursing, Primary survey, Trauma
MSC: Client Needs Category: Safe and Effective Care Environment: Management of Care
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16. A client with ARDS is receiving minimal amounts of IV fluids. The new nurse notes the client
is scheduled to receive a diuretic at this time. The nurse consults the Staff Development Nurse
to determine the best course of action. What will the new nurse do?
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a. Contact the primary health care provider.
b. Give the ordered diuretic as scheduled.
c. Request an increase in the IV rate.
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d. Calculate the client’s 24-hour fluid balance.
ANS: B
Research has shown that clients with ARDS may benefit from conservative fluid therapy
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along with diuretics to maintain fluid balance. The nurse will give the ordered diuretic as
scheduled. There is no reason to contact the provider or request an increased IV rate. The
nurse can calculate the 24-hour fluid balance, but this will not influence the administration of
the medication.
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DIF: Applying TOP: Integrated Process: Nursing Process: Implementation
KEY: ARDS, Medication
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MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

17. A nurse is assessing a client who is suspected of having ARDS. The nurse is confused that
although the client appears dyspneic and the oxygen saturation is 88% on 6 L/min of oxygen,
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the client’s lungs are clear. What explanation does the more senior nurse provide?
a. “The client is too dehydrated for moist-sounding lungs.”
b. “The client hasn’t started having any bronchospasm yet.”
c. “Lung edema is in the interstitial tissues, not the airways.”
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d. “Clients with ARDS usually have clear lung sounds.”
ANS: C
The clear lung sounds are due to the fact that the edema is found in the lung interstitial tissues,
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where it can’t be auscultated, instead of in the airways. It is not related to the client being
dehydrated or having bronchospasm. The statement about all clients with ARDS having clear
lung sounds does not provide any information.
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DIF: Understanding TOP: Integrated Process: Nursing Process: Assessment
KEY: ARDS, Nursing assessment
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
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18. A client in the emergency department has several broken ribs and reports severe pain. What
care measure will best promote comfort?
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a. Prepare to assist with intercostal nerve block.
b. abirb.com/test
Humidify the supplemental oxygen.
c. Splint the chest with a large ACE wrap.
d. Provide warmed blankets and warmed IV fluids.
ANS: A abirb.com/test
Uncomplicated rib fractures generally are simple to manage; however, opioids may be needed
for pain. For severe pain, an intercostal nerve block is beneficial. The client needs to be able
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to breathe deeply and cough so as not to get atelectasis and/or pneumonia. Humidifying the
oxygen will not help with the pain. Rib fractures are not wrapped or splinted in any way
because this inhibits chest movement. Warmed blankets and warm IV fluids are nice comfort
measures, but do not help with severe pain.
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DIF: Applying TOP: Integrated Process: Nursing Process: Implementation
KEY: Respiratory system, Pharmacological pain management
MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort
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19. A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping
blood pressure. What medication would the nurse being most beneficial?
a. Alteplase abirb.com/test
b. Enoxaparin
c. Unfractionated heparin
d. Warfarin sodium
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ANS: A
Alteplase is a “clot-busting” agent indicated in large PEs in the setting of hemodynamic
instability. The nurse knows that this drug is the priority, although heparin may be started
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initially. Enoxaparin and warfarin are not indicated in this setting.

DIF: Remembering TOP: Integrated Process: Nursing Process: Analysis

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KEY: Pulmonary embolism, Anticoagulants
MSC: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies

20. A client is brought to the emergency department after sustaining injuries in a severe car crash.
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The client’s chest wall does not appear to be moving normally with respirations, oxygen
saturation is 82%, and the client is cyanotic. What action does the nurse take first?
a. Administer oxygen and reassess.
b. Auscultate the client’s lung sounds.
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c. Facilitate a portable chest x-ray.
d. Prepare to assist with intubation.
ANS: D
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This client has signs and symptoms of flail chest and, with the other signs, needs to be
intubated and mechanically ventilated immediately. The nurse does not have time to
administer oxygen and wait to reassess, or to listen to lung sounds. A chest x-ray will be taken
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DIF: Applying TOP: Integrated Process: Nursing Process: Implementation
KEY: Trauma, Respiratory system
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MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

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21. A new nurse asks for an explanation of “refractory hypoxemia.” What answer by the staff
development nurse is best? abirb.com/test
a. “It is chronic hypoxemia that accompanies restrictive airway disease.”
b. “It is hypoxemia from lung damage due to mechanical ventilation.”
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c. “It is hypoxemia that continues even after the client is weaned from oxygen.”
d. “It is hypoxemia that persists even with 100% oxygen administration.”
ANS: D
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Refractory hypoxemia is hypoxemia that persists even with the administration of 100%
oxygen. It is a cardinal sign of acute respiratory distress syndrome. It does not accompany
restrictive airway disease and is not caused by the use of mechanical ventilation or by being
weaned from oxygen.
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DIF: Understanding TOP: Integrated Process: Teaching/Learning
KEY: Respiratory disorders, Pathophysiology
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation
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22. A nurse is caring for a client on the medical stepdown unit. The following data are related to
this client:
Subjective Information abirb.com/test
Laboratory Analysis Physical Assessment
Shortness of breath for 20 pH: 7.32 Pulse: 120 beats/min
minutes PaCO2: 28 mm Hg Respiratory rate: 34
Reports feeling frightened PaO2: 78 mm Hg breaths/min
“Can’t catch my breath” abirb.com/test
SaO2: 88% Blood pressure 158/92 mm
Hg
Lungs have crackles
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What action by the nurse is most appropriate?
a. Call respiratory therapy for a breathing treatment.
b. Facilitate a STAT pulmonary angiography.
c. Prepare for immediate endotracheal intubation.
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d. Prepare to administer intravenous anticoagulants.
ANS: B
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This client has signs and symptoms of pulmonary embolism (PE); however, many conditions
can cause the client’s presentation. The gold standard for diagnosing a PE is pulmonary
angiography. The nurse would facilitate this test as soon as possible. The client does not have
wheezing, so a respiratory treatment is not needed. The client is not unstable enough to need
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intubation and mechanical ventilation. IV anticoagulants are not given without a diagnosis of
PE.

DIF: Analyzing TOP: Integrated Process: Nursing Process: Implementation

KEY: Pulmonary embolism abirb.com/test
MSC: Client Needs Category: Physiological Integrity: Reduction of Risk Potential

MULTIPLE RESPONSE abirb.com/test

1. A nurse is caring for five clients. For which clients would the nurse assess a high risk for
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developing a pulmonary embolism (PE)? (Select all that apply.)
a. Client who had a reaction to contrast dye yesterday
b. Client with a new spinal cord injury on a rotating bed

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c. Middle-age client with an exacerbation of asthma
d. abirb.com/test
Older client who is 1 day post-hip replacement surgery
e. Young obese client with a fractured femur
f. Middle-age adult with a history of deep vein thrombosis
ANS: B, D, E abirb.com/test
Conditions that place clients at higher risk of developing PE include prolonged immobility,
central venous catheters, surgery, obesity, advancing age, conditions that increase blood
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clotting, history of thromboembolism, smoking, pregnancy, estrogen therapy, heart failure,
stroke, cancer (particularly lung or prostate), and trauma. A contrast dye reaction and asthma
pose no risk for PE.

DIF: Remembering abirb.com/test

TOP: Integrated Process: Nursing Process: Assessment
KEY: Pulmonary embolism, Risk factors
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

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2. When working with women who are taking hormonal birth control, what health promotion
measures does the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that
apply.)
a. Avoid drinking alcohol. abirb.com/test
b. Eat more omega-3 fatty acids.
c. Exercise on a regular basis.
d. Maintain a healthy weight.
e. Stop smoking cigarettes. abirb.com/test
ANS: C, D, E
Health promotion measures for clients to prevent thromboembolic events such as PE include
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maintaining a healthy weight, exercising on a regular basis, and not smoking. Avoiding
alcohol and eating more foods containing omega-3 fatty acids are heart-healthy actions but do
not relate to the prevention of PE.

DIF: Understanding
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TOP: Integrated Process: Teaching/Learning
KEY: Pulmonary embolism, Health teaching
MSC: Client Needs Category: Health Promotion and Maintenance
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3. A client with a new pulmonary embolism (PE) is anxious. What nursing actions are most
appropriate? (Select all that apply.)
a. Acknowledge the frightening nature of the illness.
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b. Delegate a back rub to the assistive personnel (AP).
c. Give simple explanations of what is happening.
d. Request a prescription for antianxiety medication.
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e. Stay with the client and speak in a quiet, calm voice.
ANS: A, B, C, E
Clients with PEs are often anxious. The nurse can acknowledge the client’s fears, delegate
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comfort measures, give simple explanations the client will understand, and stay with the
client. Using a calm, quiet voice is also reassuring. Sedatives and antianxiety medications are
not used routinely because they can contribute to hypoxia. If the client’s anxiety is interfering
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with diagnostic testing or treatment, they can be used, but there is no evidence that this is the
case.

DIF: Applying TOP: Integrated Process: Nursing Process: Implementation

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KEY: Pulmonary embolism, Psychosocial response
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MSC: Client Needs Category: Psychosocial Integrity

4. The nurse caring for mechanically ventilated clients uses best practices to prevent
ventilator-associated pneumonia. What actions are included in this practice? (Select all that
apply.) abirb.com/test
a. Adherence to proper hand hygiene
b. Administering antiulcer medication
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c. Elevating the head of the bed
d. Providing oral care per protocol
e. Suctioning the client on a regular schedule
f. Turning and positioning the client at least every 2 hours
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ANS: A, B, C, D, F
The “ventilator bundle” is a group of care measures to prevent ventilator-associated
pneumonia. Actions in the bundle include using proper hand hygiene, giving antiulcer
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medications, elevating the head of the bed, providing frequent oral care per policy, preventing
aspiration, turning and positioning, and providing pulmonary hygiene measures. Suctioning is
done as needed.
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DIF: Remembering
TOP: Integrated Process: Nursing Process: Implementation
KEY: Mechanical ventilation, Infection control
MSC: abirb.com/test
Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control

5. A nurse is caring for a client in acute respiratory failure who is on mechanical ventilation.
What actions will promote comfort in this client? (Select all that apply.)
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a. Allow visitors at the client’s bedside.
b. Ensure that the client can communicate if awake.
c. Keep the television tuned to a favorite channel.
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d. Provide back and hand massages when turning.
e. Turn the client every 2 hours or more.
ANS: A, B, D, E
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There are many basic care measures that can be employed for the client who is on a ventilator.
Allowing visitation, providing a means of communication, massaging the client’s skin, and
routinely turning and repositioning the client are some of them. Keeping the TV on will
interfere with sleep and rest.abirb.com/test
DIF: Applying TOP: Integrated Process: Nursing Process: Implementation
KEY: Mechanical ventilation, Comfort measures
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MSC: Client Needs Category: Physiological Integrity: Basic Care and Comfort

6. The nurse caring for mechanically ventilated clients knows that older adults are at higher risk
for weaning failure. What age-related changes contribute to this? (Select all that apply.)
a. Chest wall stiffness abirb.com/test
b. Decreased muscle strength
c. Inability to cooperate
d. Less lung elasticity
e. Poor vision and hearing
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f. Chronic anemia

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ANS: A, B, D
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Age-related changes that increase the difficulty of weaning older adults from mechanical
ventilation include increased stiffness of the chest wall, decreased muscle strength, and less
elasticity of lung tissue. Not all older adults have an inability to cooperate or poor sensory
acuity. Anemia can make it difficult to wean a client, but this is not a normal age-related
change.
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DIF: Remembering TOP: Integrated Process: Nursing Process: Analysis
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KEY: Mechanical ventilation, Older adult
MSC: Client Needs Category: Health Promotion and Maintenance

7. A 100-kg client has developed ARDS and needs mechanical ventilation. Which of the
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following are potentially correct ventilator management choices? (Select all that apply.)
a. Tidal volume: 600 mL
b. Volume-controlled ventilation
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c. PEEP based on oxygen saturation
d. Suctioning every hour
e. High-frequency oscillatory ventilation
f. Limited turning for ventilator pressures
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ANS: A, C, E
The client with ARDS who needs mechanical ventilation benefits from “open lung” and lung
protective strategies, such as using low tidal volumes (6 mL/kg body weight).
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Pressure-controlled ventilation is preferred due to the high pressures often required in these
clients. PEEP usually starts at 5 cm H2O and adjusted to keep oxygen saturations in an
acceptable range. Suctioning may need to be frequent due to secretions, but is not scheduled
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hourly. High-frequency oscillatory ventilation is an alternative to traditional modes of
ventilation. Early mobility is encouraged as is turning and positioning the client.

DIF: Understanding
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Integrated Process: Nursing Process: Implementation
KEY: Mechanical ventilation, ARDS
MSC: Client Needs Category: Physiological Integrity: Physiological Adaptation

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