Uworld Respiratory #6

The nurse is teaching a client with advanced chronic obstructive pulmonary disease who was prescribed oral theophylline. Which client statement indicates that additional teaching is required? a. I need to avoid caffeinated products b. I need to get my blood drug levels checked periodically c. I need to report anorexia and sleeplessness d. I take Cimetidine rather than omeprazole for heartburn.

Theophylline is a bronchodilator with a low therapeutic index and a narrow therapeutic range (10-20 mcg/mL). The serum level should be monitored frequently to avoid severe adverse effects. Toxicity is likely to occur at levels >20 mcg/mL. Individual titration is based on peak serum theophylline levels, so it is necessary to draw a blood level 30 minutes after dosing. Theophylline can cause seizures and life-threatening arrhythmias. Toxicity is usually due to intentional overdose or concurrent intake of medications that increase serum theophylline levels. Cimetidine and ciprofloxacin can dramatically increase serum theophylline levels (>80%). Therefore, they should not be used in these clients. (Option 1) Caffeinated products (eg, coffee, cola, chocolate) should be avoided as they would intensify the adverse effects (eg, tachycardia, insomnia, restlessness) of theophylline. (Option 2) The best way to prevent toxicity is to monitor drug levels periodically and adjust the dose. (Option 3) The signs of toxicity that should be reported are anorexia, nausea, vomiting, restlessness, and insomnia. Educational objective:Theophylline can cause seizures and life-threatening arrhythmias due to its narrow therapeutic range (10-20 mcg/mL). The dose is adjusted based on peak drug levels, obtained 30 minutes after the dose is given. Clients should avoid caffeinated products and medications that increase serum theophylline levels (eg, cimetidine, ciprofloxacin).

A client with chronic kidney disease has a large pleural effusion. What findings characteristic of a pleural effusion does the nurse expect? Select all that apply. a. Chest pain during inhalation b. Diminished breath sounds c. Dyspnea d. Hyperresonance on percussion e. Wheezing

A pleural effusion is an abnormal collection of fluid (>15 mL) in the pleural space that prevents the lung from expanding fully, resulting in decreased lung volume, atelectasis, and ineffective gas exchange. It is usually secondary to another disease (eg, heart failure, pneumonia, nephrotic syndrome). Pleural effusions are diagnosed by chest x-ray or CT scan. Thoracentesis can be performed to remove fluid from the pleural space and resolve symptoms. Clients commonly report dyspnea with a nonproductive cough, as well as pleural chest pain with respirations (Options 1 and 3). On assessment, clients have diminished breath sounds, dullness to percussion, decreased tactile fremitus, and decreased movement over the affected lung (Option 2). (Option 4) Fluid outside the lung interrupts the transmission of sound, resulting in decreased fremitus and dullness with percussion in pleural effusion. Percussion is hyperresonant in clients with pneumothorax. (Option 5) Wheezing indicates an obstructive process (eg, asthma, chronic obstructive pulmonary disease) and is not typical in pleural effusion. Educational objective:A pleural effusion is an abnormal collection of fluid (>15 mL) in the pleural space that prevents the lung from expanding fully, resulting in decreased lung volume, atelectasis, and ineffective gas exchange. Clients report dyspnea and pain with respirations and have diminished breath sounds with dullness to percussion over the affected area.

The nurse develops a care plan for a critically ill client with acute respiratory distress syndrome (ARDS) who is on a mechanical ventilator. What is the priority nursing diagnosis (ND)? a. Imbalanced nutrition b. Impaired gas exchange c. Impaired tissue integrity d. Risk for infection

ARDS involves damage to the alveolar-capillary membrane, the blood-gas barrier across which oxygen diffuses into the alveoli. When the membrane is damaged, the alveoli collapse and fluid leaks into the alveolar space and impairs gas exchange. Impaired gas exchange related to alveolar-capillary changes and ventilation-perfusion imbalance is the priority ND for a client with ARDS. (Option 1) Imbalanced nutrition (less than body requirements) related to increased metabolic needs and inability to ingest foods due to endotracheal intubation, is an appropriate ND for the client with ARDS. However, it does not pose the greatest threat to survival and is not the priority ND. (Option 3) Impaired tissue (integumentary) related to altered circulation, immobility, and nutritional deficits is an appropriate ND for the client with ARDS. However, it does not pose the greatest threat to survival and is not the priority ND. (Option 4) Risk for infection related to the presence of an endotracheal tube, frequent suctioning, intravenous devices, and indwelling catheters is an appropriate ND for the client with ARDS. However, it does not pose the greatest threat to survival and is not the priority ND. Educational objective:ARDS involves damage to the alveolar-capillary membrane, resulting in fluid leakage into the alveolar space. Impaired gas exchange related to alveolar-capillary changes and ventilation-perfusion imbalance is an appropriate ND for a client with ARDS.

A nurse is caring for an elderly client who had a colectomy for removal of cancer 2 days ago. The client is becoming increasingly restless. He has been given intravenous morphine every 2 hours for severe pain. Respirations are 28/min and shallow. Which arterial blood gas (ABG) results best indicate that the client is in acute respiratory failure (ARF) and needs immediate intervention? a. PaO2 49; PaCO2 60 b. PaO2 64; PaCO2 45 c. PaO2 70; PaCO2 30 d. PaO2 86; PaCO2 25

ARF is defined as inadequate gas exchange that is intrapulmonary (pneumonia, pulmonary embolism) or extrapulmonary (head injury, opioid overdose) in origin. Respiratory failure associated with an alteration in O2 transfer or absorption is type I hypoxemic failure (eg, acute respiratory distress syndrome, pulmonary edema, shock). Respiratory failure associated with carbon dioxide (CO2) retention is type II hypercapnic, or ventilatory failure (eg, chronic obstructive pulmonary disease, myasthenia gravis, flail chest). ARF is a potential complication of major surgical procedures, especially those involving the thorax and abdomen, as in this client. ABG values that indicate the presence of ARF are PaO2 ≤60 mm Hg (8.0 kPa) or PaCO2 ≥50 mm Hg (6.67 kPa). ARF occurs quickly over time (minutes to hours), and so there is no physiologic compensation and pH is ≤7.30. Immediate intervention with high O2 concentrations is indicated, and noninvasive or invasive, positive-pressure mechanical ventilation may be necessary. (Option 2) PaO2 64 mm Hg (8.5 kPa) indicates hypoxemia, and PaCO2 45 mm Hg (6.0 kPa) is within the normal range, but results do not meet the criteria for ARF. (Option 3) PaO2 70 mm Hg (9.3 kPa) indicates hypoxemia, and PaCO2 30 mm Hg (4.0 kPa) indicates increased ventilation and an alkalotic state, but results do not meet the criteria for ARF. (Option 4) PaO2 86 mm Hg (11.5 kPa) is within normal range, and PaCO2 25 mm Hg (3.33 kPa) indicates increased ventilation and an alkalotic state, but results do not meet the criteria for ARF. Educational objective:Type I hypoxemic failure is associated with an alteration in O2 transfer (eg, acute respiratory distress syndrome, pulmonary edema, shock). Type II hypercapnic, or ventilatory, failure is associated with CO2 retention (eg, chronic obstructive pulmonary disease, myasthenia gravis, flail chest). ABG values that indicate the presence of ARF are PaO2 ≤60 mm Hg (8.0 kPa), PaCO2 ≥50 mm Hg (6.67 kPa), and pH ≤7.30.

The nurse in the outpatient procedure unit is caring for a client immediately post bronchoscopy. Which assessment data indicate that the nurse needs to contact the health care provider immediately? a. Absence of gag reflex b. Bright red blood mixed with sputum c. Headache d. Respirations 10/min and saturation of 92%

An endoscopic bronchoscopy is a procedure in which the bronchi are visualized with a flexible fiberoptic bronchoscope that is passed down through the nose (or through the mouth, or endotracheal or tracheostomy tube). The client receives mild sedation (eg, midazolam) to provide relaxation and promote comfort. A topical anesthetic (eg, lidocaine, benzocaine) is applied to the nares and throat to suppress the gag and cough reflexes, prevent laryngospasm, and facilitate passage of the scope. The procedure is done to diagnose, obtain tissue samples for biopsy, lavage, and to remove secretions (mucus plugs), foreign objects, or abnormal tissue with a laser. Blood-tinged sputum is common and can occur from inflammation of the airway, but hemoptysis of bright red blood can indicate hemorrhage, especially if a biopsy was performed. Other complications include hypoxemia, hypercarbia, hypotension, laryngospasm, bradycardia, pneumothorax (rare), and adverse effects from medications used before and during the procedure. (Option 1) Absence of the gag reflex for about 2 hours following the procedure is expected from the topical anesthetic. (Option 3) Headache is not a complication of bronchoscopy. (Option 4) Respirations of 10/min and saturation of 92% are expected after mild sedation before and/or or during the procedure. Educational objective:Immediately post bronchoscopy, the nurse monitors for associated potential complications, including hemoptysis, hypoxemia, hypercarbia, hypotension, laryngospasm, bradycardia, pneumothorax, and adverse effects from medications used before and during the procedure.

The nurse responds to the call light of a client with chronic obstructive pulmonary disease (COPD) who says, "I can't breathe." The client seems to be having difficulty breathing and is nervous and tremulous. Vital signs are stable, oxygen saturation is 92% on 2 L, and there are clear breath sounds bilaterally. Which intervention would be most appropriate at this time? a. Administer albuterol nebulizer b. Assist the client in identifying the trigger and ways to avoid it c. Coach the client through the controlled breathing exercises d. Continue to monitor oxygen saturation

Anxiety is an emotional reaction to a perceived threat. For the client with COPD, the fear of having difficulty breathing can actually trigger difficulty breathing, which worsens as the client's anxiety increases. This client is stable, with no obvious cause of shortness of breath. The nurse should intervene by calmly coaching the client through breathing exercises, which will promote relaxation and help alleviate the anxiety that is causing the client to feel short of breath. (Option 1) The client's lung sounds are clear bilaterally and so albuterol, a bronchodilator used for wheezing, will not be helpful. Its action as an adrenergic agonist may cause tachycardia and tremulousness and actually worsen the client's anxiety. (Option 2) Trigger avoidance and problem solving are appropriate strategies for long-term control of anxiety and shortness of breath. However, these are not appropriate at this time as the client has acute symptoms that need to be controlled. (Option 4) This client has normal oxygen saturation. Constant monitoring is not likely to alleviate the symptoms unless the client is reassured by this knowledge. However, the client's anxiety may actually be worsened by worrying about the saturation results and the alarms that are likely to be triggered by monitoring. Educational objective:Anxiety is common in clients with COPD and can contribute to difficulty breathing. In the client with acute shortness of breath and normal assessment findings, appropriate interventions are controlled breathing and relaxation.

A client comes to the emergency department and reports headache, nausea, and shortness of breath after being stranded at home without electricity due to severe winter weather. While collecting a history, which question is most important for the nurse to ask? a. Are you up to date with your annual flu shot and other vaccinations? b. Have you had difficulty eating or drinking in the last few days c. How have you been keeping your house warm during this weather? d. Is there anything that you have found that relieves your symptoms?

Carbon monoxide (CO) is a colorless, odorless gas produced by burning fuel (eg, oil, kerosene, coal, wood) in a poorly ventilated setting. CO toxicity (poisoning) is most often associated with smoke inhalation from structure fires, but is also generated by furnaces/hot water heaters fueled by natural gas or oil, coal or wood stoves, fireplaces, and engine exhaust. Clients with CO toxicity often have nonspecific symptoms, and the diagnosis can be missed. It is important to assess for possible CO exposure to initiate appropriate emergency care and prevent hypoxic neurologic impairment. To help identify elevated CO levels in the home, the nurse can ask about the following: Similar symptoms in other family members, or an illness in an indoor pet that developed at the same time Fuel-burning heating/cooking appliances; risk of CO toxicity increases in the fall and winter due to increased used of heat sources in an enclosed space (Option 3) (Options 1, 2, and 4) It is important to reconcile the client's vaccinations, obtain a nutritional history, and explore the nature of the client's symptoms, but it is essential to rule out the possibility of CO toxicity given the circumstances of this client's illness. Educational objective:Carbon monoxide (CO) toxicity can occur when fuel-burning (eg, wood, coal) stoves or appliances are used in poorly ventilated settings. Clients with CO toxicity may have vague symptoms (eg, headache, dizziness, nausea), so it is important to assess for possible CO exposure to prevent delay of appropriate emergency care.

A client with chronic bronchitis tells the home health nurse of being exhausted all day due to coughing all night and being unable to sleep. The client can feel thick mucus in the chest and throat. Which interventions can the nurse suggest to help mobilize secretions and improve sleep? Select all that apply. a. Increase fluids to at least 8 glasses (2-3 L) of water a day b. Sleep with a cool mist humidifier c. Take prescribed guaifenesin cough medicine before bedtime d. Use abdominal breathing and the huff cough technique at bedtime e. Use pursed lip breathing during the night

Chronic bronchitis is characterized by excessive mucus production, chronic cough, and recurrent respiratory tract infections. Interventions to help reduce viscosity of mucus, facilitate secretion removal, and promote comfort include the following: Increasing oral fluids to 2-3 L/day if not contraindicated prevents dehydration and keeps secretions thin Cool mist humidifier increases room humidity of inspired air Guaifenesin (Robitussin) is an expectorant that reduces the viscosity of thick secretions by increasing respiratory tract fluid; drinking a full glass of water after taking the medication is recommended. Abdominal breathing with the huff, a forced expiratory cough technique, is effective in mobilizing secretions into the large airways so that they can be expectorated Chest physiotherapy (postural drainage, percussion, vibration) Airway clearance handheld devices, which use the principle of positive expiratory pressure to help loosen secretions when the client exhales through the mouthpiece (Option 5) Pursed lip breathing prolongs exhalation, reduces air trapping in the lungs, and decreases dyspnea. It does not help to thin secretions. Educational objective:Interventions to help reduce viscosity of mucus, facilitate secretion removal, and promote comfort in clients with chronic bronchitis include the following: Increasing oral fluids to 2-3 L/day if not contraindicated Cool mist humidifier to increase room humidity Guaifenesin (Robitussin), an expectorant, to reduce viscosity of secretions Huff coughing

A 6-month-old client has been diagnosed with cystic fibrosis. Which of the following would be appropriate for the registered nurse to teach to the parents? a. Monitor for and report development of a "white pupil" b. Perform manual chest physiotherapy c. Place child in knee-chest position during hypercyanotic episode d. Provide low calorie diet to prevent obesity

Cystic fibrosis is an inherited autosomal recessive disorder of the exocrine glands that results in physiologic alterations in the respiratory, gastrointestinal, and reproductive systems. It is theorized that the chloride transport alternation and resulting thickened mucus inhibit normal ciliary action and cough clearance, and the lungs become clogged with mucus. The thickened mucus harbors bacteria. Over time, airways develop chronic colonization and frequent respiratory infections result. Bronchial hygiene therapy, such as manual chest physiotherapy, is used. For physiotherapy, various positions are used, and this should be performed before meals to avoid a full stomach and resultant regurgitation or vomiting. (Option 1) A white pupil (leukocoria, or cat's-eye reflex) is one of the first signs of retinoblastoma, an intraocular malignancy of the retina. Other symptoms include an absent red reflex, asymmetric or of a differing color in the affected eye, and fixed strabismus (constant deviation of one eye from the other). This disease is not related to cystic fibrosis. (Option 3) Hypercyanotic episodes are associated with tetralogy of Fallot. The knee-chest position increases systemic vascular resistance in the lower extremities. In addition, irritating stimuli should be limited, and supplemental oxygen should be provided. (Option 4) The pancreatic ducts become damaged, and there is a decreased ability to digest fats and proteins and absorb fat-soluble vitamins. Pancreatic enzyme supplements are used. Children with cystic fibrosis tend to be hungry but underweight due to a decreased ability to use fat and its calories. Educational objective:Cystic fibrosis causes thickened mucus, making respiratory infections common. Treatment includes chest physiotherapy performed usually before meals.

A client has an allergy skin test that is positive for dust mites. The nurse provides instruction on environmental interventions the client can use to control symptoms by reducing exposure to this allergen. Which intervention would be described in this teaching? a. Allergy shots or sublingual immunotherapy b. Antihistamine use c. Vacuum carpeting once a week d. Wash bed linens in hot water once a week

Environmental interventions can be very effective in controlling dust mite allergy symptoms. The bed is a common site of allergen exposure. Dust mite allergen exposure can be greatly reduced by washing bed linens every 1-2 weeks with hot water. High temperature (>140 F [60 C]) is needed to kill the dust mites; warm or cold water washing should not be recommended. Other environmental interventions that can help control symptoms include the use of special allergy-proof mattress and pillow covers and vacuuming the mattress on a regular basis. (Option 1) Allergy shots and sublingual immunotherapy can reduce allergy symptoms by exposing the immune system to the allergen over time, reducing the immune response with subsequent exposure. However, this is not an environmental intervention. (Option 2) Antihistamines can be effective in controlling allergy symptoms. However, they are not an environmental intervention. (Option 3) If possible, clients with allergy or asthma should avoid having carpeting in the home. If carpeting is used, vacuuming should be done almost daily (not weekly) to remove the dust mites. Educational objective:Environmental interventions for reducing exposure to dust mite allergen in the bed include frequently washing linens with hot (>140 F [60 C]) water and using special mattress and pillow covers.

The nurse is assessing a client an hour after a left lung lobectomy. The client is awake, alert, and oriented, and reports pain of 6 on a 0-10 scale. Pulse oximetry is 92% on 4 L oxygen via nasal cannula. The chest tube is set to continuous water seal suction at -20 cm H2O. The collection chamber has accumulated 320 mL of frank red drainage in the last hour. What is the priority nursing action? a. Clamp the chest tube immediately b. Increase oxygen to 6 L via n/c c. Medicate the client for pain and document the findings d. Notify the health care provider immediately

Following lung surgery, a chest tube is inserted into the pleural space to create a negative vacuum to re-inflate the lung and prevent air from re-entering the space. A client with a chest tube should be assessed for signs of air/fluid in the chest (eg, diminished breath sounds), excessive drainage (>100 mL/hr), pain, and infection at the drainage site. The collection chamber should be inspected every hour for the first 8 hours following surgery, then every 8 hours until it is removed. Excess drainage of frank red blood is indicative of hemorrhage and must be managed immediately. The priority action is to contact the health care provider for further management. (Option 1) Clamping the chest tube prevents air or fluid from leaving the pleural space, which may cause a reciprocal tension pneumothorax. The chest tube is clamped only a few hours prior to removal, momentarily to check for an air leak, or if the drainage apparatus needs to be changed. (Option 2) Although a pulse oximetry of 92% is low, this is an expected finding following lung surgery. (Option 3) Pain following surgery is a concern and the client will require medication; however, hemorrhage is the priority. Educational objective:A client with a chest tube should be assessed for signs of air/fluid in the chest (eg, diminished breath sounds), excessive drainage (>100 mL/hr), pain, and infection at the drainage site. Excess drainage of frank red blood is indicative of hemorrhage and must be managed immediately.

A nurse is caring for a college athlete who was recently diagnosed with moderate persistent asthma. Which common asthma trigger should the nurse teach this client to avoid? a. Latex containing products b. Penicillin antibiotics c. Second hand cigarette smoke d. Strenoud physical activity

In clients with asthma, the airways are chronically inflamed with varying degrees of airway obstruction that can be exacerbated by exposure to triggering agents. Common asthma triggers include: Allergens: Dander (eg, cat, dog), dust mites, pollen Drugs: Beta blockers; nonsteroidal anti-inflammatory agents, including aspirin Environmental: Chemicals, sawdust, soaps/detergents Infectious: Upper respiratory infections Intrinsic: Emotional stress, gastrointestinal reflux disease Irritants: Aerosols/perfumes, cigarette smoke (including secondhand smoke), dry/polluted air (Option 3) Clients must be able to identify their individual triggers and avoid or learn to manage them. (Options 1 and 2) Penicillin antibiotics and latex-containing products may commonly trigger allergic reactions in many clients but do not commonly trigger asthma exacerbations in clients without these allergies. (Option 4) Although physical activity is an asthma trigger, athletes with asthma do not need to avoid activity altogether. Rather, they may take an inhaled bronchodilator 20 minutes before activity to help prevent exercise-induced asthma attacks. In addition, this client may be prone to minor musculoskeletal injuries (eg, sprains, strains) due to an active lifestyle; the nurse should teach about alternatives to common over-the-counter nonsteroidal anti-inflammatory medications that may be used for analgesia (eg, acetaminophen [Tylenol]). Educational objective:The nurse should teach an active young adult with asthma to identify and manage common triggers of asthma attacks, including cigarette smoke and nonsteroidal anti-inflammatory medications. Clients with asthma should take an inhaled bronchodilator 20 minutes before athletic activity to prevent exercise-induced asthma attacks.

The nurse is gathering data on a client with obstructive sleep apnea. Which findings are consistent with this client's diagnosis? Select all that apply. a. Difficulty arousing from sleep b. Excessive daytime sleepiness c. Morning headaches d. Postural collapse and falling e. Snoring during sleep f. Witness episodes of apnea

Obstructive sleep apnea (OSA) is the most common type of breathing disorder during sleep and is characterized by repeated periods of apnea (>10 seconds) and diminished airflow (hypopnea). A partial or complete obstruction occurs due to upper airway narrowing that results from relaxation of the pharyngeal muscles or from the tongue falling back on the posterior pharynx due to gravity. During periods of apnea, desaturation (hypoxemia) and hypercapnia occur; these stimulate the client to arouse and breathe momentarily to restore airflow. These cycles of apnea and restored airflow can occur several hundred times per night, resulting in restless and fragmented sleep. Partners of clients with OSA witness loud snoring, apnea episodes, and waking with gasping or a choking sensation (Options 5 and 6). During the day, clients experience morning headaches, irritability, and excessive sleepiness. Excessive daytime sleepiness can lead to poor work performance, motor vehicle crashes, and increased mortality (Options 2 and 3). (Option 1) Frequent (not difficult) arousal from sleep is associated with OSA. (Option 4) Cataplexy is a brief loss of skeletal muscle tone or weakness that can result in a client falling down. It is associated with narcolepsy, a chronic neurologic sleep disorder. Educational objective:At night, clients with obstructive sleep apnea experience repeated periods of apnea, loud snoring, and interrupted sleep. During the day, morning headaches, irritability, and excessive sleepiness are common.

The nurse caring for a client with left lobar pneumonia responds to an alarm from the continuous pulse oximeter. The client is short of breath with an oxygen saturation of 78%. After applying oxygen, the nurse should place the client in which position to improve oxygenation? a. left lateral b. right lateral c. supine d. trendelenburg

Pneumonia is a lung infection resulting in decreased gas exchange in the affected lung lobes. The alveoli in the affected lobes become blocked with purulent fluid, which impairs ventilation. However, these alveoli continue to receive perfusion from the pulmonary artery, resulting in poorly oxygenated or deoxygenated blood. This ventilation-to-perfusion (V/Q) mismatch, or pulmonary shunt, may result in hypoxia and respiratory distress. Blood flow in the lungs is partially influenced by gravity, meaning that blood flows in higher volumes to dependent parts of the lung. Therefore, a client with left lobar pneumonia should be positioned in right lateral position with the unaffected (good) lung down (eg, right lung) to increase blood flow to the lung most capable of oxygenating blood (Option 2). (Option 1) Left lateral positioning will worsen hypoxia by decreasing blood flow to the unaffected (ie, right) lung. (Options 3 and 4) Positioning in supine or Trendelenburg position does not promote increased perfusion to the unaffected lung, which is needed to improve hypoxia. Educational objective:Pneumonia (ie, infection of the lungs) causes decreased gas exchange in the affected lung lobes, which can lead to hypoxia and respiratory distress. Clients with unilateral pneumonia should be positioned with the unaffected (ie, good) lung down to improve perfusion and oxygenation.

A client with pneumonia is transferred from the medical unit to the intensive care unit due to sepsis and worsening respiratory failure. Based on the nurse's progress note, which assessment data are most important for the nurse to report to the health care provider (HCP)? Click on the exhibit button for additional information. Progress notes 1845 Productive cough of large amount of tan mucus, scattered rhonchi, and crackles in bases. Arterial blood gas (ABG) results: PaCO2 35 mm Hg, PaO2 90 mm Hg on nasal oxygen at 6L/min. Temperature 101.1 F (38.3 C). On vancomycin for 2 days.______________RN 1945 Repeat ABG: PaCO2 33 mm Hg, PaO2 89 mm Hg on 50% oxygen via face mask.______________RN 2045 Repeat ABG: PaCO2 32 mm Hg, PaO2 86 mm Hg on 100% oxygen via total rebreather mask.______________RN a. Cough with mucus production b. Refractory hypoxemia c. Scattered rhonchi and crackles d. Temp 101 F

Refractory hypoxemia is the hallmark of acute respiratory distress syndrome (ARDS), a progressive form of acute respiratory failure that has a high mortality rate. It can develop following a pulmonary insult (eg, aspiration, pneumonia, toxic inhalation) or nonpulmonary insult (eg, sepsis, multiple blood transfusions, trauma) to the lung. The insult triggers a massive inflammatory response that causes the lung tissue to release inflammatory mediators (leukotrienes, proteases) that cause damage to the alveolar-capillary (A-C) membrane. As a result of the damage, the A-C membrane becomes more permeable, and intravascular fluid then leaks into the alveolar space, resulting in a noncardiogenic pulmonary edema. The lungs become stiff and noncompliant, which makes ventilation and oxygenation less than optimal and results in increased work of breathing, tachypnea and alkalosis, atelectasis, and refractory hypoxemia. Profound hypoxemia despite high concentrations of oxygen is a key sign of ARDS and is the most important assessment finding to report to the HCP. (Options 1 and 3) Cough with mucus production and scattered rhonchi and crackles are expected findings in a client with pneumonia. (Option 4) Temperature is an expected finding in a client with pneumonia who is receiving antibiotic therapy. The white blood cell count can still be elevated after 2 days of antibiotic therapy. Educational objective:Refractory hypoxemia is the inability to improve oxygenation with increases in oxygen concentration. It is the hallmark of ARDS, a progressive form of acute respiratory failure that has a high mortality rate.

The hospice nurse is caring for an actively dying client who is unresponsive and has developed a loud rattling sound with breathing ("death rattle") that distresses family members. Which prescription would be most appropriate to treat this symptom? a. Atropine sublingual drops b. Lorazepam sublingual tablet c. Morphine sublingual liquid d. Ondansetron sublingual tablet

The "death rattle" is a loud rattling sound with breathing that occurs in a client who is actively dying. When the client cannot manage airway secretions, the movement of these secretions during breathing causes a noisy rattling sound. This can distress family and friends at the bedside of the dying client. The "death rattle" can be treated using anticholinergic medications to dry the client's secretions. Medications include atropine drops administered sublingually or a transdermal scopolamine patch. (Option 2) Lorazepam is a benzodiazepine that is used to treat anxiety and restlessness in terminally ill clients. It can be effective for alleviating dyspnea exacerbated by anxiety, but it is ineffective for controlling secretions (the cause of the "death rattle"). (Option 3) Morphine is an opioid analgesic that is effective for pain treatment as well as terminal dyspnea. The client is not exhibiting these symptoms, so morphine would be inappropriate. (Option 4) Ondansetron will help the nausea and vomiting but is not very effective for treating the "death rattle." Educational objective:The "death rattle" is a noisy rattling sound with breathing commonly seen in a dying client who is unresponsive and no longer able to manage airway secretions. Anticholinergic medications such as transdermal scopolamine or atropine sublingual drops effectively treat this symptom by drying up the excess secretions.