Respiratory

The nurse determines that which client is at greatest risk for development of acute respiratory distress syndrome (ARDS)?

A client with pancreatitis and gram-negative sepsis RationaleThe client with pancreatitis and gram-negative sepsis is at greatest risk of developing ARDS because of the presence of two risk factors for its development.

A client who is experiencing severe respiratory acidosis has a potassium level of 6.2 mEq/L. The nurse determines this result is best characterized by which interpretation?

Expected and indicates that acidosis has driven hydrogen ions into the cell, forcing potassium out RationaleWith severe respiratory acidosis, compensatory mechanisms fail. As hydrogen ion concentrations continue to rise, they are driven into the cell, forcing intracellular potassium out. This is an expected finding in this situation.

The nurse is monitoring the respiratory status of a client following insertion of a tracheostomy. The nurse understands that oxygen saturation measurements obtained by pulse oximetry may be inaccurate if the client has which coexisting problem?

Hypotension

A client with chronic obstructive pulmonary disease (COPD) on bed rest is weaned from the ventilator before transferring to a medical unit. To adequately restore client strength before getting the client out of bed, which is the priority client activity for the nurse to incorporate in the plan of care?

Instruct the client to reposition himself. RationaleTherapy for COPD usually includes glucocorticoids that carry a high risk of complications such as muscle and bone wasting, fragile skin, impaired immune functioning, and fluid retention, so the nurse must restore some client strength before attempting to get the client out of the bed. Because the client is likely to be weak from bed rest and lack of activity during mechanical ventilation and treatment, the nurse establishes outcomes for the client, including restoration of pulmonary, cardiovascular, and musculoskeletal functioning to return to baseline functioning. To begin safely, the nurse instructs the client to reposition himself in bed to exert force on muscles and bones, helping to reverse the tissue loss incurred during bed rest.

The nurse is providing endotracheal suctioning to a client who is mechanically ventilated, when the client becomes restless and tachycardic. Which action should the nurse take?

Monitor vital signs and discontinue attempts at suctioning until the client is stabilized. RatioanleIf a client becomes cyanotic or restless or develops tachycardia, bradycardia, or another abnormal heart rhythm while suctioning, the nurse must discontinue suctioning attempts until the client is stabilized. It is also important to monitor vital signs and pulse oximetry and preoxygenate the client for any repeated suctioning attempts. If the client's condition continues to deteriorate, then the respiratory department and health care provider may need to be notified.