NCLEX book The client with Acute Respiratory Distress Syndrome (ARDS)

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.

131. The nurse has placed the intubated client with acute respiratory distress syndrome (ARDS) in prone position for 30 minutes. Which factors 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 SpO, and Po, have decreased. 4. the client is tachycardic with drop in blood increased skin breakdown and A 5. The face has increased skin breakdown and edema.

4. prone

132. To improve the oxygenation of a client with acute repiratory distress syndrome (ARDS) who is receiving mechanical ventilation, the nurse should place the client in which position? 1. supine 2. semi-Fowler's 3. lateral 4. prone

1. Monitor serum creatinine and blood urea nitrogen levels. 4. Administer humidified oxygen. 5. Auscultate the lungs.

133. 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, what should the nurse do? Select all that apply. 1. Monitor serum creatinine and blood urea nitrogen levels. 2. Administer a sedative. 3. Keep the head of the bed flat. 4. Administer humidified oxygen. 5. Auscultate the lungs.

4. replacing fiuids adequately during hypovolemic states

134.which nursing 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

2. hypoxia not responsive to oxygen therapy

135. The nurse interprets which finding 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. PACO2

136. A client with acute respiratory distress syndrome (ARDS) is showing signs of increased dyspnea. The nurse reviews a report of blood gas values signs that recently arrived (see report)

1. initiating IV sedation.

137. 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 imporving. Using the SBAR (Situation Background Assessment Recommendation) technique for communication, the nurse calls the healthcare provider (HCP) with the recommendation for: 1. initiating IV sedation. 2. starting a high-protein diet. 3. Providing pain medication. 4. increasing the ventilator rate.

1. arterial oxygen level of 46 mm Hg (6.1 kPa)

138. A client, diagnosed with acute pancreatitis 5 days ago, is experiencing respiratory distress. Which finding should the nurse report to the healthcare provider (HCP)? 1. arterial oxygen level of 46 mm Hg (6.1 kPa) 2. respirations of 12 breaths/min 3. lack of adventitious lung sounds 4. Oxygen saturation of 96% on room air

i 1. The client is severely hypoxic.

139. 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 conclusion 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

3. mechanical ventilation

140. Which action should the nurse aaticipate 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

1. septic shock

141. Which condition can place at risk for acute respiratory distress syndrome (ARDS)? 1. septic shock 2. chronic obstructive pulmonary disease 3. asthma 4. heart failure

4. auscultating breath sounds bilaterally

142, Which assessment 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. Suction if cough is ineffective.

143. To promote effective airway clearance in a client with acute respiratory distress, what should the nurse do? 1. Administer oxygen every 2 hours. 2. Turn the client every 4 hours. 3. Administer sedatives to promote rest. 4. Suction if cough is ineffective.

1. gastrointestinal hemorrhage

144. Which complication is associated with męchanical ventilation? 1. gastrointestinal hemorrhage 2. immunosuppression 3. increased cardiac output 4. pulmonary emboli