ACUTE RESPIRATORY DISTRESS DISORDER
A. Is it the phase where the lung
Questions
1) In a small town fire department,
firefighter Jack had a challenging call
responding to a massive house fire. His
dedication to his job meant he was right
in the thick of it, battling the flames,
and unfortunately, he ended up inhaling
a significant amount of smoke.
Two days later, a severe lack of oxygen
triggered complications. Jack’s
condition worsened so much that he
required an artificial airway and a
ventilator to assist with his breathing.
Given this situation, what medical
condition do you think Jack has most
probably developed?
A. Bronchitis, inflammation of the
lining of the bronchial tubes.
B. Pneumonia, an infection that
inflames the air sacs in one or both
lungs.
C. Atelectasis, partial or complete
collapse of the entire lung.
D. Acute respiratory distress syndrome
(ARDS), a life-threatening condition
that prevents enough oxygen from
getting to the lungs and into the blood.
2) In a bustling intensive care unit,
Nurse Martin is taking care of an
ARDS patient, Mr. Thompson, who’s
now moving into the fibrotic phase of
the syndrome. Martin, with a
meticulous eye for detail, takes note of
the various developments that this stage
brings. How would you describe this
fibrotic phase of ARDS?
initiates self-repair, marking the point
where the patient either starts to
improve or the condition begins to
decline?
B. Could it be the stage where fibrous
tissue begins to form, making the lungs
less flexible, thus increasing the effort
to breathe, and consequently, the
oxygen demand?
C. Or, is this the phase where fluids
infiltrate the alveoli, leading to the
collapse of alveoli and bronchi, and
resulting in decreased lung
compliance?
3) Nurse Lauren, a seasoned
professional, is at the helm of the ICU
in a bustling city hospital. Tonight, she
is attending to a male patient who has
been diagnosed with acute respiratory
distress syndrome. Part of her role
involves taking measurements via a
pulmonary artery catheter.
In her latest reading, she notes that the
pulmonary capillary wedge pressure
(PCWP) is at 12mm Hg. As an
experienced practitioner, how should
Nurse Lauren interpret this finding?
A. As a typical and anticipated value.
B. As an unusually low and unexpected
value.
C. As a value that is uncertain and not
anticipated.
D. As a high value that was to be
expected.
4) Matthew, a dedicated nurse, was
attending to a male patient who had
ACUTE RESPIRATORY DISTRESS DISORDER
been admitted following a major car
accident. The patient suffered from
chest trauma and was promptly
intubated. Suddenly, the high-pressure
alarm on the ventilator blares, grabbing
Matthew’s immediate attention. He
rushes over to check the patient and
finds an absence of breath sounds in the
right upper lobe of the patient’s lung.
Matthew’s mind instantly races, trying
to identify what other signs he should
be on the lookout for to pinpoint the
cause of this alarming development.
What could this situation indicate?
A. A misplaced endotracheal tube.
B. The onset of acute respiratory
distress syndrome.
C. The presence of a pulmonary
embolism.
D. The development of a right
pneumothorax.
5) At Mercy General Hospital, Nurse
Benjamin is attending to an African
American male patient who came in
with an asthma attack, now
experiencing acute respiratory distress.
Benjamin knows that detecting
cyanosis, a sign of poor oxygenation,
can be more challenging in individuals
with darker skin.
Given this situation, where should
Nurse Benjamin focus his inspection to
identify cyanosis in this patient?
A. The mucous membranes.
B. The lips.
C. The earlobes.
D. The nail beds.
6) At Haven County Hospital, medical
professionals, including seasoned
respiratory therapist David, are
constantly working to manage various
conditions affecting their patients. One
such condition is acute respiratory
distress syndrome (ARDS), a severe
and often life-threatening disorder.
David reflects on his years of practice
and thinks about the following
statement: “Management of ARDS is
largely supportive, with limited options
available to reverse the process.” Is this
statement accurate or misleading?
A. Accurate
B. Misleading
7) In the bustling trauma unit of St.
Luke’s Hospital, Nurse Emily
diligently cares for a patient who has
recently suffered a right femur fracture.
Given the nature of the injury, Emily is
watchful for any signs that may hint at
a fat embolism, a potential
complication in such cases.
What symptoms should she be on the
lookout for that might suggest the
development of a fat embolism?
A. Is it a series of migraine-like
headaches?
B. Could it be numbness in the right
leg?
C. Might it be muscle spasms in the
right thigh?
ACUTE RESPIRATORY DISTRESS DISORDER
D. Or could it be the onset of acute
respiratory distress syndrome?
8) At Hope General Hospital, Nurse
Rebecca is responsible for a female
patient who has sustained multiple
traumas. Aware of the risk of the
patient developing acute respiratory
distress syndrome (ARDS), Rebecca is
on high alert for early signs of this
serious condition.
What should she consider as the earliest
indicator of ARDS?
A. The presence of inspiratory crackles.
B. Bilateral wheezing during
respiration.
C. An escalated respiratory rate.
D. The appearance of intercostal
retractions.
9) Amid the hustle and bustle of City
General Hospital, Registered Nurse
Joshua is providing care to a patient
suffering from acute respiratory distress
syndrome (ARDS). Joshua knows that
understanding the different phases of
ARDS is critical for effective care.
When thinking about the Acute
Exudative Phase of ARDS, how would
Joshua describe it?
A. Does it involve fluids shifting into
the alveoli, leading to the collapse of
the alveoli and bronchi, and resulting in
a loss of lung compliance?
B. Is this the phase where fibrous tissue
begins to form, the lungs don’t expand
well, and increased effort to breathe
escalates the demand for oxygen?
C. Or, is this the stage where the lung
begins to repair itself, and it’s the
turning point where the patient starts to
improve or their condition worsens?
10) In a critical care unit, Nurse Sophie
is attending to a male patient suffering
from acute respiratory distress
syndrome resulting from shock. His
condition rapidly worsens,
necessitating endotracheal (ET)
intubation and mechanical ventilation.
When the high-pressure alarm on the
mechanical ventilator suddenly rings
out, Sophie swiftly initiates a check to
identify the cause.
What condition would most likely
trigger the high-pressure alarm on the
ventilator?
A. Could it be due to an alteration
in the oxygen concentration
without resetting the oxygen
level alarm?
B. Might it be due to the kinking
of the ventilator tubing?
C. Is it possible that an ET cuff
leak has occurred?
D. Or could it be due to a
disconnected ventilator tube?
ACUTE RESPIRATORY DISTRESS DISORDER
Answers and
Rationales
1) Correct answer:
D. Acute respiratory distress
syndrome (ARDS), a life-threatening
condition that prevents enough oxygen
from getting to the lungs and into the
blood. In the case of Jack, given the
exposure to the massive house fire and
the inhalation of a significant amount
of smoke, the most likely condition he
developed is acute respiratory distress
syndrome (ARDS). ARDS is a severe
lung condition leading to low oxygen
levels in the blood. It can be triggered
by many factors, but smoke inhalation
is a common cause because it can lead
to direct injury to the lung tissue.
Smoke inhalation causes the release of
inflammatory mediators that increase
the permeability of the alveolar-
capillary membrane, leading to the
accumulation of fluid in the lungs,
reducing lung compliance and
impairing gas exchange, which
manifests as difficulty breathing and
requires mechanical ventilation.
Think of the lung as a sponge and air as
water. Normally, air (water) can easily
fill the sponge (lung), but in ARDS, the
sponge is covered with a thick layer of
plastic wrap (due to inflammation and
fluid), making it difficult for air (water)
to reach the sponge.
Incorrect answer options:
A. Bronchitis, inflammation of the
lining of the bronchial tubes. Although
smoke inhalation can cause bronchitis
by irritating the lining of the bronchial
tubes, this condition typically results in
a persistent cough and mucus
production. It would not typically result
in the severe respiratory failure seen in
Jack’s case, requiring artificial airway
and ventilator support.
B. Pneumonia, an infection that
inflames the air sacs in one or both
lungs. Pneumonia is generally caused
by infection with bacteria, viruses, or
other microorganisms, and less
commonly by inhalation of solvents or
heavy smoke. Jack could potentially
develop pneumonia secondary to
ARDS, but it would not be the
immediate consequence of smoke
inhalation.
C. Atelectasis, partial or complete
collapse of the entire lung. Atelectasis
can occur as a result of a blockage of
the air passages or pressure on the
outside of the lung. While atelectasis
might occur in a fire victim due to
prolonged bed rest or decreased deep
breathing, it’s less likely to be the
primary diagnosis in the acute phase
post smoke inhalation.
2) Correct answer:
B. Could it be the stage where
fibrous tissue begins to form, making
the lungs less flexible, thus increasing
the effort to breathe, and
consequently, the oxygen
demand? The fibrotic phase is the third
and final stage of ARDS, typically
starting one to three weeks after the
initial lung injury. The main
characteristic of this phase is the
development of fibrous tissue in the
ACUTE RESPIRATORY DISTRESS DISORDER
lungs due to the ongoing inflammatory
response. This fibrous tissue reduces
the flexibility of the lungs, making
them stiffer and thus increasing the
work of breathing and oxygen demand.
Oxygen exchange becomes more
difficult as the fibrosis progresses, and
this may lead to low levels of oxygen in
the blood (hypoxemia).
Think of ARDS as a reaction to a burn.
Initially, there’s swelling and
inflammation (exudative phase), then a
scab forms (proliferative phase), and
finally, if healing doesn’t proceed
properly, scar tissue can form (fibrotic
phase). Just as scar tissue can limit
movement if it forms on skin, fibrous
tissue can limit the lungs’ ability to
expand and contract, making breathing
more difficult.
Incorrect answer options:
A. Is it the phase where the lung
initiates self-repair, marking the point
where the patient either starts to
improve or the condition begins to
decline? This is a bit misleading. While
it’s true that this phase may dictate
whether the patient recovers or the
disease progresses, the description is
too vague and doesn’t directly identify
the specific changes seen in the fibrotic
phase of ARDS.
C. Or, is this the phase where fluids
infiltrate the alveoli, leading to the
collapse of alveoli and bronchi, and
resulting in decreased lung
compliance? This describes the
exudative phase of ARDS, which is the
initial phase that typically occurs
within 72 hours of the initial injury or
insult. In this phase, fluids, proteins,
and inflammatory cells fill the alveoli,
leading to the collapse of alveoli and
bronchioles, and resulting in decreased
lung compliance.
3) Correct answer:
A. As a typical and anticipated value.
The pulmonary capillary wedge
pressure (PCWP), also known as the
pulmonary artery occlusion pressure,
provides an estimation of the left atrial
pressure. A normal PCWP is between 6
and 12 mm Hg. Hence, a reading of 12
mm Hg in this context is within the
typical range and anticipated.
Think of the PCWP as a “thermometer”
for the pressure in the left side of the
heart, just as a thermometer gives us an
accurate measurement of body
temperature. A normal body
temperature is around 98.6°F (37°C),
and similarly, a normal PCWP is
between 6 and 12 mm Hg. Just as we
wouldn’t be alarmed by a body
temperature of 98.6°F, we wouldn’t be
alarmed by a PCWP of 12 mm Hg.
Incorrect answer options:
B. As an unusually low and unexpected
value. This statement is incorrect. A
PCWP of 12 mm Hg falls within the
normal range, not unusually low.
C. As a value that is uncertain and not
anticipated. This statement is incorrect.
A PCWP of 12 mm Hg is within the
normal range and is an anticipated
value.
D. As a high value that was to be
expected. This statement is incorrect. A
PCWP of 12 mm Hg is at the upper
ACUTE RESPIRATORY DISTRESS DISORDER
limit of the normal range, but it is not
considered high. Moreover, in ARDS, a
normal PCWP is expected, because this
syndrome primarily affects the lung
parenchyma and not the heart. In fact,
one of the criteria for diagnosing
ARDS is a PCWP of 18 mm Hg or less
(when available), which helps to
distinguish ARDS from cardiogenic
pulmonary edema.
4) Correct answer:
D. The development of a right
pneumothorax. Given the scenario
described, the patient most likely
developed a right pneumothorax.
Pneumothorax occurs when air enters
the pleural space and the lung
collapses, leading to an interruption in
the exchange of gasses. Signs of a
pneumothorax can include a sudden
onset of respiratory distress, decreased
or absent breath sounds on the affected
side (as mentioned in the question), and
a high-pressure alarm on the ventilator
due to increased resistance to air flow.
Imagine a balloon (the lung) inside a
box (the chest cavity). Normally, the
balloon fills up the entire box. But if
there’s a hole in the balloon, air leaks
out, causing the balloon to deflate.
Similarly, a pneumothorax occurs when
air enters the pleural space (the box),
leading to a collapsed lung (deflated
balloon).
Incorrect answer options:
A. A misplaced endotracheal tube. This
could potentially cause an absence of
breath sounds on one side, particularly
if the tube is inserted too far and only
ventilating one lung. However, this
would usually not trigger a high-
pressure alarm on the ventilator.
B. The onset of acute respiratory
distress syndrome. ARDS typically
affects both lungs, and would not cause
an absence of breath sounds in only one
lobe of the lung. Furthermore, ARDS
generally does not cause a high-
pressure alarm on the ventilator unless
severe.
C. The presence of a pulmonary
embolism. While a pulmonary
embolism can cause sudden respiratory
distress, it typically does not cause an
absence of breath sounds in one lobe of
the lung or trigger a high-pressure
alarm on the ventilator.
5) Correct answer:
A. The mucous membranes. When
assessing cyanosis in individuals with
darker skin, it is most accurate to
inspect the mucous membranes
(especially the oral mucosa) and the
conjunctiva of the eyes. This is because
these areas are less affected by skin
pigment and allow for a more accurate
evaluation of color changes related to
oxygenation.
Imagine trying to tell if a red shirt is
fading. If the shirt is in bright sunlight,
it’s hard to tell if the color is changing.
But if you look at an area that’s usually
hidden from the sun (like under the
collar or the inside hem), you might get
a better idea of any color change.
Similarly, when assessing cyanosis in
people with darker skin, you need to
check areas where the color change due
ACUTE RESPIRATORY DISTRESS DISORDER
to lack of oxygen will be more evident
– like the mucous membranes.
Incorrect answer options:
B. The lips. While the lips can show
signs of cyanosis, they may not be the
most reliable location in people with
darker skin because of the potential for
natural pigmentation to mask cyanosis.
C. The earlobes. The earlobes can be a
place to check for cyanosis, but they
are not typically the first choice for
assessing cyanosis, especially in people
with darker skin, because the thicker
skin and tissue in this area might make
cyanosis less apparent.
D. The nail beds. In darker-skinned
individuals, cyanosis may not be
readily evident in the nail beds because
of the increased amount of melanin
present.
6) Correct answer:
A. Accurate. This statement is indeed
accurate. Acute Respiratory Distress
Syndrome (ARDS) management is
largely supportive. The mainstay of
ARDS management includes
mechanical ventilation to maintain
oxygenation, fluid management, and
treating the underlying cause, if
identified. Unfortunately, there is no
specific treatment available to reverse
the inflammatory process that occurs in
the lungs during ARDS.
Imagine ARDS as a forest fire causing
damage to a forest (the lungs).
Firefighters (healthcare providers) can’t
stop the fire immediately; they can only
try to control the spread, protect
unaffected areas, and help the forest
recover after the fire subsides.
Similarly, in ARDS, medical
professionals try to support the patient,
prevent complications, and manage the
symptoms while the body heals itself.
Incorrect answer option:
B. Misleading. This is not correct as the
statement given is accurate, not
misleading. ARDS is a complex
condition that develops due to
inflammation and damage to the alveoli
in the lungs, and currently, no
definitive treatments exist that can
directly reverse this process.
7) Correct answer:
D. Or could it be the onset of acute
respiratory distress syndrome? A fat
embolism is a serious complication that
can occur after a fracture, especially of
the long bones like the femur. Fat
droplets from the bone marrow can
enter the bloodstream and eventually
reach the lungs, leading to a condition
that can manifest similarly to acute
respiratory distress syndrome (ARDS).
It may cause symptoms such as
shortness of breath, rapid breathing,
hypoxia, and mental confusion due to
reduced oxygenation to the brain.
These signs can appear within 24-72
hours post-injury.
Consider a fat embolism as a roadblock
on a busy highway (the bloodstream).
This roadblock (fat globules) hinders
the traffic flow (blood carrying
oxygen), leading to congestion and
inefficiency. The places that rely on
this traffic (organs like the lungs and
ACUTE RESPIRATORY DISTRESS DISORDER
brain) face difficulties, manifesting as
symptoms of distress.
Incorrect answer options:
A. Is it a series of migraine-like
headaches? While a fat embolism can
cause neurological symptoms due to
decreased oxygen supply to the brain, it
would not typically manifest as
migraines. Neurological manifestations
are more likely to include confusion,
drowsiness, or even coma in severe
cases.
B. Could it be numbness in the right
leg? Numbness in the leg could be
related to the injury itself or a nerve
injury, but it’s not typically a sign of a
fat embolism.
C. Might it be muscle spasms in the
right thigh? While pain and spasms
might occur due to the fracture, these
are not typically symptoms of a fat
embolism.
8) Correct answer:
C. An escalated respiratory rate. The
earliest indicator of Acute Respiratory
Distress Syndrome (ARDS) is often an
increased respiratory rate, also known
as tachypnea. This increase is due to
the body’s attempt to meet its oxygen
demands as the efficiency of gas
exchange in the lungs is compromised.
Hypoxemia, or low levels of oxygen in
the blood, usually accompanies this
increased respiratory rate, despite
supplemental oxygen. The dyspnea or
difficulty in breathing may not be
severe at first but can worsen rapidly.
Think of the increased respiratory rate
as a car speeding up because there’s a
leak in the fuel line (oxygen exchange
is compromised in ARDS). The car (the
body) tries to go faster (breathes faster)
to get to its destination before it runs
out of fuel (oxygen).
Incorrect answer options:
A. The presence of inspiratory crackles.
Crackles might be heard during a
respiratory assessment of a patient with
ARDS, but this is not typically one of
the earliest signs. It’s usually found
later as the disease progresses and fluid
fills the alveoli.
B. Bilateral wheezing during
respiration. Wheezing is not a typical
symptom of ARDS. Wheezing is more
commonly associated with diseases that
cause narrowing of the airways, such as
asthma or chronic obstructive
pulmonary disease (COPD).
D. The appearance of intercostal
retractions. Intercostal retractions can
occur in severe respiratory distress, but
it’s usually not an early sign of ARDS.
They may appear as the disease
progresses and the patient struggles to
breathe.
9) Correct answer:
A. Does it involve fluids shifting into
the alveoli, leading to the collapse of
the alveoli and bronchi, and resulting
in a loss of lung compliance? The
Acute Exudative Phase is the initial
phase of ARDS, typically within the
first 1 to 7 days after the initial insult or
injury. The hallmark of this phase is
increased permeability of the
pulmonary capillaries, leading to
leakage of protein-rich fluid into the
alveoli. This fluid disrupts surfactant
production, which in turn results in
ACUTE RESPIRATORY DISTRESS DISORDER
alveolar collapse (atelectasis),
contributing to decreased lung
compliance (the ease at which the lungs
can expand). This significantly impairs
gas exchange, leading to hypoxemia.
Imagine ARDS as a garden hose (the
alveoli) used to water a garden (the
body’s cells). Normally, water
(oxygen) flows easily through it. In the
Acute Exudative Phase, imagine that
the hose gets punctures (increased
capillary permeability), and instead of
the water going where it’s needed, it
starts to leak out (fluid filling the
alveoli). This results in less water
getting to the plants (less oxygen to the
body’s cells), and the hose itself
becomes less flexible (loss of lung
compliance).
Incorrect answer options:
B. Is this the phase where fibrous tissue
begins to form, the lungs don’t expand
well, and increased effort to breathe
escalates the demand for oxygen? This
description is more indicative of the
Fibrotic Phase of ARDS, which
typically occurs 2-3 weeks after the
onset. This is characterized by the
proliferation of fibroblasts and
deposition of collagen, which stiffens
the lungs and makes breathing more
laborious.
C. Or, is this the stage where the lung
begins to repair itself, and it’s the
turning point where the patient starts to
improve or their condition
worsens? This is a depiction of the
Proliferative Phase of ARDS, which
typically occurs 1-2 weeks after the
initial injury. It’s during this phase that
the body attempts to heal, and lung
damage either starts to resolve or
progress further into the fibrotic stage.
10) Correct answer:
B. Might it be due to the kinking of
the ventilator tubing? A high-pressure
alarm on a ventilator typically indicates
increased resistance to airflow. This
resistance can occur due to various
reasons such as a kinked or obstructed
tube, a mucus plug in the airway, or the
patient coughing, biting the tube, or
fighting the ventilator. Among the
given options, the most likely cause is
the kinking of the ventilator tubing,
which obstructs the airflow and
increases the pressure, thereby setting
off the alarm.
Think of the ventilator as a bicycle
pump, the tube as a hose, and the
patient’s lungs as the bicycle tire. If the
hose gets kinked, it will be harder to
push air (pressure) through it into the
tire (the lungs). The pump (the
ventilator) senses this increased
resistance and signals (alarms) that
something’s wrong.
Incorrect answer options:
A. Could it be due to an alteration in
the oxygen concentration without
resetting the oxygen level
alarm? Changing the oxygen
concentration would affect the oxygen
alarm if it’s not adjusted accordingly,
but it would not trigger a high-pressure
alarm.
C. Is it possible that an ET cuff leak has
occurred? A leak in the ET cuff would
likely cause a low-pressure alarm rather
ACUTE RESPIRATORY DISTRESS DISORDER

than a high-pressure one because the

system’s integrity has been
compromised, leading to a drop in
pressure.
D. Or could it be due to a disconnected
ventilator tube? A disconnected
ventilator tube would also likely trigger
a low-pressure alarm, as the pressure in
the system would drop due to the
disconnection.