AH4 - Week 2 - Lippincott 11ed - Ch. 3 Test 4 - The Client with Acute Respiratory Distress Syndrome (ARDS) - Exam 1

137. A client with acute respiratory distress syndrome (ARDS) has fine crackles at lung bases and the respirations are shallow at a rate of 28 breaths/min. The client is restless and anxious. In addition to monitoring the arterial blood gas results, the nurse should do which of the following? Select all that apply. 1. Monitor serum creatinine and blood urea nitrogen levels. 2. Administer a sedative. 3. Keep the head of the bed at. 4. Administer humidifed oxygen. 5. Auscultate the lungs.

1, 4, 5 1. Monitor serum creatinine and blood urea nitrogen levels. 4. Administer humidifed oxygen. 5. Auscultate the lungs. Acute respiratory distress syndrome (ARDS) may cause renal failure and superinfection, so the nurse should monitor urine output and urine chemistries. Treatment of hypoxemia can be complicated because changes in lung tissue leave less pulmonary tissue available for gas exchange, thereby causing inadequate perfusion. Humidified oxygen may be one means of promoting oxygenation. The client has crackles in the lung bases, so the nurse should continue to assess breath sounds. Sedatives should be used with caution in clients with ARDS. The nurse should try other measures to relieve the client's restlessness and anxiety. The head of the bed should be elevated to 30 degrees to promote chest expansion and prevent atelectasis.

149. Which of the following nursing interventions would promote effective airway clearance in a client with acute respiratory distress? 1. Administering oxygen every 2 hours. 2. Turning the client every 4 hours. 3. Administering sedatives to promote rest. 4. Suctioning if cough is ineffective.

1. Administering oxygen every 2 hours. Gastrointestinal hemorrhage occurs in about 25% of clients receiving prolonged mechanical ventilation because of the development of stress ulcers. Clients who are receiving steroid therapy and those with a previous history of ulcers are most likely to be at risk. Other possible complications include incorrect ventilation, oxygen toxicity, fluid imbalance, decreased cardiac output, pneumothorax, infection, and atelectasis.

142. A client, diagnosed with acute pancreatitis 5 days ago, is experiencing respiratory distress. The nurse should report which of the following to the health care provider? 1. Arterial oxygen level of 46 mm Hg. 2. Respirations of 12. 3. Lack of adventitious lung sounds. 4. Oxygen saturation of 96% on room air.

1. Arterial oxygen level of 46 mm Hg. Manifestations of adult respiratory distress syndrome (ARDS) secondary to acute pancreatitis include respiratory distress, tachypnea, dyspnea, fever, dry cough, fine crackles heard throughout lung fields, possible confusion and agitation, and hypoxemia with arterial oxygen level below 50 mm Hg. The nurse should report the arterial oxygen level of 46 mm Hg to the health care provider. A respiratory rate of 12 is normal and not considered a sign of respiratory distress. Adventitious lung sounds, such as crackles, are typically found in clients with ARDS. Oxygen saturation of 96% is satisfactory and does not represent hypoxemia or low arterial oxygen saturation.

141. A client with acute respiratory distress syndrome (ARDS) is on a ventilator. The client's peak inspiratory pressures and spontaneous respiratory rate are increasing, and the PO2 is not improving. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the physician with the recommendation for: 1. Initiating IV sedation. 2. Starting a high-protein diet. 3. Providing pain medication. 4. Increasing the ventilator rate.

1. Initiating IV sedation. The client may be fighting the ventilator breaths. Sedation is indicated to improve compliance with the ventilator in an attempt to lower peak inspiratory pressures. The workload of breathing does indicate the need for increased protein calories; however, this will not correct the respiratory problems with high pressures and respiratory rate. There is no indication that the client is experiencing pain. Increasing the rate on the ventilator is not indicated with the client's increased spontaneous rate.

146. Which of the following conditions can place a client at risk for acute respiratory distress syndrome (ARDS)? 1. Septic shock. 2. Chronic obstructive pulmonary disease. 3. Asthma. 4. Heart failure.

1. Septic shock. The two risk factors most commonly associated with the development of ARDS are gram-negative septic shock and gastric content aspiration. Nurses should be particularly vigilant in assessing a client for onset of ARDS if the client has experienced direct lung trauma or a systemic inflammatory response syndrome (which can be caused by any physiologic insult that leads to widespread inflammation). Chronic obstructive pulmonary disease, asthma, and heart failure are not direct causes of ARDS.

148. Which of the following nursing interventions would promote effective airway clearance in a client with acute respiratory distress? 1. Administering oxygen every 2 hours. 2. Turning the client every 4 hours. 3. Administering sedatives to promote rest. 4. Suctioning if cough is ineffective.

4. Suctioning if cough is ineffective. The nurse should suction the client if the client is not able to cough up secretions and clear the airway. Administering oxygen will not promote airway clearance. The client should be turned every 2 hours to help move secretions; every 4 hours is not often enough. Administering sedatives is contraindicated in acute respiratory distress because sedatives can depress respirations.

143. A client has the following arterial blood gas values: pH, 7.52; PaO2, 50 mm Hg (6.7 kPa); PaCO2, 28 mm Hg (3.72 kPa); HCO3-, 24 mEq/L (24 mmol/L). Based upon the client's PaO2, which of the following conclusions would be accurate? 1. The client is severely hypoxic. 2. The oxygen level is low but poses no risk for the client. 3. The client's PaO2 level is within normal range. 4. The client requires oxygen therapy with very low oxygen concentrations.

1. The client is severely hypoxic. Normal PaO2 level ranges from 80 to 100 mm Hg (10.6 to 13.3 kPa). When PaO2 falls to 50 mm Hg (6.7 kPa), the nurse should be alert for signs of hypoxia and impending respiratory failure. An oxygen level this low poses a severe risk for respiratory failure. The client will require oxygenation at a concentration that maintains the PaO2 at 55 to 60 mm Hg (7.3 to 8 kPa) or more.

139. The nurse interprets which of the following as an early sign of acute respiratory distress syndrome (ARDS) in a client at risk? 1. Elevated carbon dioxide level. 2. Hypoxia not responsive to oxygen therapy. 3. Metabolic acidosis. 4. Severe, unexplained electrolyte imbalance.

2. Hypoxia not responsive to oxygen therapy. A hallmark of early ARDS is refractory hypoxemia. The client's PaO2 level continues to fall, despite higher concentrations of administered oxygen. Elevated carbon dioxide and metabolic acidosis occur late in the disorder. Severe electrolyte imbalances are not indicators of ARDS.

135. The nurse has placed the intubated client with acute respiratory distress syndrome (ARDS) in prone position for 30 minutes. Which of the following would require the nurse to discontinue prone positioning and return the client to the supine position? Select all that apply. 1. The family is coming in to visit. 2. The client has increased secretions requiring frequent suctioning. 3. The SpO2 and PO2 have decreased. 4. The client is tachycardic with drop in blood pressure. 5. The face has increased skin breakdown and edema.

3, 4, 5 3. The SpO2 and PO2 have decreased. 4. The client is tachycardic with drop in blood pressure. 5. The face has increased skin breakdown and edema. The prone position is used to improve oxygenation, ventilation, and perfusion. The importance of placing clients with ARDS in prone positioning should be explained to the family. The positioning allows for mobilization of secretions and the nurse can provide suctioning. Clinical judgment must be used to determine the length of time in the prone position. If the client's hemodynamic status, oxygenation, or skin is compromised, the client should be returned to the supine position for evaluation. Facial edema is expected with the prone position, but the skin breakdown is of concern.

145. Which of the following interventions should the nurse anticipate in a client who has been diagnosed with acute respiratory distress syndrome (ARDS)? 1. Tracheostomy. 2. Use of a nasal cannula. 3. Mechanical ventilation. 4. Insertion of a chest tube.

3. Mechanical ventilation. Endotracheal intubation and mechanical ventilation are required in ARDS to maintain adequate respiratory support. Endotracheal intubation, not a tracheostomy, is usually the initial method of maintaining an airway. The client requires mechanical ventilation; nasal oxygen will not provide adequate oxygenation. Chest tubes are used to remove air or fluid from intrapleural spaces.

147. Which of the following assessments is most appropriate for determining the correct placement of an endotracheal tube in a mechanically ventilated client? 1. Assessing the client's skin color. 2. Monitoring the respiratory rate. 3. Verifying the amount of cuff inflation. 4. Auscultating breath sounds bilaterally.

4. Auscultating breath sounds bilaterally. Auscultation for bilateral breath sounds is the most appropriate method for determining cuff placement. The nurse should also look for the symmetrical rise and fall of the chest and should note the location of the exit mark on the tube. Assessments of skin color, respiratory rate, and the amount of cuff inflation cannot validate the placement of the endotracheal tube.

136. The nurse has calculated a low PaO2/FIO2 (P/F) ratio less than 150 for a client with acute respiratory distress syndrome (ARDS). The nurse should place the client in which position to improve oxygenation, ventilation distribution, and drainage of secretions? 1. Supine. 2. Semi-Fowler's. 3. Lateral side. 4. Prone.

4. Prone. Prone positioning is used to improve oxygenation in clients with ARDS who are receiving mechanical ventilation. The positioning allows for recruitment of collapsed alveolar units, improvement in ventilation, reduction in shunting, mobilization of secretions, and improvement in functional reserve capacity (FRC). When the client is supine, side-to-side repositioning should be done every 2 hours with the head of the bed elevated at least 30 degrees.

144. A client has the following arterial blood gas values: pH, 7.52; PaO2, 50 mm Hg (6.7 kPa); PaCO2, 28 mm Hg (3.7 kPa); HCO3-, 24 mEq/L (24 mmol/L). The nurse determines that which of the following is a possible cause for these findings? 1. Chronic obstructive pulmonary disease (COPD). 2. Diabetic ketoacidosis with Kussmaul's respirations. 3. Myocardial infarction. 4. Pulmonary embolus.

4. Pulmonary embolus. A PaCO2 of 28 mm Hg (3.7 kPa) and PaO2 of 50 mm Hg (6.7 kPa) are both abnormal; the PaO2 of 50 mm Hg (6.7 kPa) signifes acute respiratory failure. In evaluating possible causes for this disorder, the nurse should consider conditions that lead to hypoxia and hyperventilation, such as pulmonary embolus. COPD is typically associated with respiratory acidosis and elevated PaCO2. The client with diabetic ketoacidosis most often has metabolic acidosis. A myocardial infarction does not often cause an acid-base imbalance because the primary problem is cardiac in origin.

138. Which of the following interventions would be most likely to prevent the development of acute respiratory distress syndrome (ARDS)? 1. Teaching cigarette smoking cessation. 2. Maintaining adequate serum potassium levels. 3. Monitoring clients for signs of hypercapnia. 4. Replacing fluids adequately during hypovolemic states.

4. Replacing fluids adequately during hypovolemic states. One of the major risk factors for development of ARDS is hypovolemic shock. Adequate fluid replacement is essential to minimize the risk of ARDS in these clients. Teaching smoking cessation does not prevent ARDS. An abnormal serum potassium level and hypercapnia are not risk factors for ARDS.