ARDS

The nurse is working with the physician to wean a client with acute respiratory distress syndrome (ARDS) from the ventilator. Which of the following interventions will the nurse avoid during the process of weaning? Daily hygiene care Suctioning the client Administration of sedatives Antibiotic administration

Administration of sedatives Rationale: The client with ARDS who is being weaned from the ventilator should not be given sedatives that depress respiration. When the client is being weaned, the nurse optimizes respiratory function to promote successful weaning. Daily hygiene, antibiotics, and suctioning are all appropriate for the weaning client.

The nurse is caring for a client who is being discharged after recovering from acute respiratory distress syndrome (ARDS). The family asks if the client is out of danger and if normal activities can be resumed. Which of the following will the nurse explain to the client and family? "The client is out of danger and can resume normal activities." "The client will be ready for normal routines in about a year." "Maximal respiratory function should return in six months." "The client will never recover fully."

Answers with Rationale, C. Maximal respiratory function should return in six months Full recovery from ARDS takes about six months, so the client is taught measures to prevent further lung trauma. The client is not out of danger at discharge. One year is much longer than the typical recovery time. Some clients may never fully recover, but a six-month time period is generally correct.

A nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing acute respiratory distress syndrome (ARDS). Select all that apply. A client who experience a drug overdose A client following coronary artery bypass graft surgery A client who has a hemoglobin of 15.1 mg/dl A client who has dysphagia A client who experience a near-drowning incident

Answers with rationale, A, B, D, E a. d/t damage to CNS b. d/t trauma to chest c. No-if they had a low hemoglobin they could be at risk d. d/t difficulty swallowing and risk for aspiration e. d/t to trauma to lungs and cerebral edema

A nurse is assessing a client who has a chest tube and drainage system in place. Which of the following are expected findings? (Select all that apply). Continuous bubbling in the water seal chamber Gentle constant bubbling in the suction control chamber Rise and fall in the level of water in the water seal chamber with inspiration and expiration Exposed sutures without dressing Drainage system upright at the chest level

Answers with rationale, B. Gentle bubbling in the suction control chamber is an expected finding as air is being removed, C. A rise and fall of the fluid level in the water seal chamber upon inspiration and expiration indicates that the drainage system is functioning properly A. Continuous bubbling in the water seal chamber indicates an air leak D. the nurse should cover the sutures at the insertion site with an airtight dressing E. The drainage system should be maintained in an upright position below the level of the client's chest

A nurse is caring for a client who is experiencing respiratory distress. Which of the following are early clinical manifestations of hypoxemia? Select all that apply. Confusion Pale skin Hypotension Elevated blood pressure Bradycardia

Answers with rationale, B. pale skin, D. elevated blood pressure Confusion is a late sign of hypoxemia Hypotension is a late sign of hypoxemia Bradycardia is a late sign of hypoxemia

A nurse is caring for a client receiving vecuronium for acute respiratory distress syndrome. Which of the following medications should the nurse anticipate administering with the medication? (Select all that apply). dexamethasone furosemide midazolam famotidine fentanyl

Answers with rationale, C. Sedative med used to treat clients w/ards, E. Pain med used to treat clients w/ards when a neuromuscular blocking agent such as vecuronium is administered Lasix is a diuretic Pepcid is a h2 receptor antagonist for upset stomach Decadron is a corticosteroid for inflammation

A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium to a client who has ARDS. Which of the following statements by the newly licensed nurse indicates understanding of the teaching. a. this medication is given to treat infection b. this medication is given to facilitate ventilation c. this medication is given to decrease inflammation d. this medication is given to reduce anxiety

b. facilitate ventilation

A nurse in the ED is assessing a client who was in a motor vehicle crash. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68, HR 124/min, RR 38/min, temp 38.6 (101.4) and O2 92% on RA. Which of the following actions should the nurse take first? a. obtain a CXR b. prepare for a chest tube insertion c. administer oxygen via a high-flow mask d. initiate IV access

c. O2 via high flow mask ABC priority

The nurse is caring for a client who is being discharged after recovering from acute respiratory distress syndrome (ARDS). The family asks if the client is out of danger and if normal activities can be resumed. Which of the following will the nurse explain to the client and family? "Maximal respiratory function should return in six months." "The client will never recover fully." "The client will be ready for normal routines in about a year." "The client is out of danger and can resume normal activities."

"Maximal respiratory function should return in six months." Rationale: Full recovery from ARDS takes about six months, so the client is taught measures to prevent further lung trauma. The client is not out of danger at discharge. One year is much longer than the typical recovery time. Some clients may never fully recover, but a six-month time period is generally correct.

Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the family members of a patient with ARDS is correct? "PEEP will prevent fibrosis of the lung from occurring." "PEEP will push more air into the lungs during inhalation." "PEEP allows the ventilator to deliver 100% oxygen to the lungs." "PEEP prevents the lung air sacs from collapsing during exhalation."

Answer with rationale, D. By preventing alveolar collapse during expiration, PEEP improves gas exchange and oxygenation. PEEP will not prevent the fibrotic changes that occur with ARDS, push more air into the lungs, or change the fraction of inspired oxygen (FI02) delivered to the patient.

A client who develops acute respiratory distress syndrome (ARDS) is exhibiting hypoxemia that is unresponsive to oxygen therapy. In explaining the client's condition to the family, the nurse would incorporate which of the following concepts? Blood is shunted past alveoli with no ventilation. The individual has difficulty expelling air trapped in the alveoli. There is excess surfactant production by the alveoli. Thick secretions block the airways.

Answer with rationale, A. Blood is shunted past alveoli with no ventilation The client is experiencing metabolic acidosis. Sodium bicarbonate acts by directly raising the pH of body fluids; it is the drug of choice for restoring plasma pH to normal limits. Sodium chloride is used to treat hyponatremia; ammonium chloride is used to treat severe metabolic alkalosis; and potassium chloride treats hypokalemia

A 12-year-old is being treated for acute respiratory distress syndrome. Which assessment finding would be indicative of the nursing diagnosis of impaired gas exchange? Heart rate of 100 bpm Respiratory rate of 60/min Oxygen saturation of 62% Bicarbonate level of 38 mEq/L

Answer with rationale, C Oxygen saturation of 62% Normal levels of oxygen saturation are 95-100%. The client with an O2 level of 62% is not exchanging gases. Heart rate increase is a sign of many disorders and by itself does not signify impaired gas exchange. A respiratory rate of 60 signifies respiratory distress but does not imply impaired gas exchange. Bicarbonate levels are an indication of kidney function.

The nurse is caring for a patient who was hospitalized 2 days earlier with aspiration pneumonia. Which assessment information is most important to communicate to the HCP? a. The patient has scattered crackles throughout the posterior lung bases. b. The patient's temperature is 101.5F after 2 days of IV antibiotic therapy. c. The patient's sp02 has dropped to 90%, although the 02 flow rate has been increased. d. The patient has a cough that is productive of blood-tinged sputum.

Answer with rationale, C. The patient's dropping sp02 despite having an increase in FIO2 indicates the possibility of ARDS Pink tinged sputum and crackles are not unusual in a patient with pneumonia, although they do require continued monitoring. The continued temperature elevation indicated a possible need to change antibiotics, but not an urgent concern as the progression toward hypoxemia despite an increase in 02 flow rate.

A nurse is assessing a client following a bronchoscopy. Which of the following findings should the nurse report to the MD? Blood-tinged sputum Sore throat Bronchospasms Dry, nonproductive cough

Answer with rationale, C. Bronchospasms can indicate the client is having difficulty maintaining a patent airway. The nurse should notify the provider immediately. Other symptoms are expected findings following a bronchoscopy

A client who develops acute respiratory distress syndrome (ARDS) is exhibiting hypoxemia that is unresponsive to oxygen therapy. In explaining the client's condition to the family, the nurse would incorporate which of the following concepts? Thick secretions block the airways. Blood is shunted past alveoli with no ventilation. The individual has difficulty expelling air trapped in the alveoli. There is excess surfactant production by the alveoli.

Blood is shunted past alveoli with no ventilation. Rationale: One of the primary alterations occurring with ARDS is the collapse of alveoli, causing loss of ventilation in these areas. Perfusion may be normal, but gas exchange is impaired because of inadequate ventilation. Surfactant production decreases with ARDS, a factor that impairs adequate gas exchange. Air does not become trapped in hyperinflated alveoli in ARDS; instead, alveoli collapse.

In a client with respiratory distress, which finding by the nurse most manifests a worsening clinical state? Tachycardia Increased respiratory rate Cyanosis Agitation

Cyanosis Rationale: Increased respiratory rate, tachycardia, and agitation are all early signs of respiratory distress. Cyanosis develops later in the progression of respiratory distress.

The nurse is monitoring a client who is mechanically ventilated due to acute respiratory distress syndrome (ARDS). The nurse determines that the client has met the outcome for reduced anxiety when the client: (Select all that apply.) Is able to rest. Has a relaxed facial expression. Thrashes the legs. Keeps eyes open. Fights the ventilator.

Has a relaxed facial expression. Is able to rest. Rationale: The client with reduced anxiety will be able to rest and will have a relaxed facial expression. The intubated client who thrashes the legs, keeps eyes open, and fights breathing with the ventilator is demonstrating anxiety.

The client with an acute lung injury has developed acute respiratory distress syndrome (ARDS). The nurse monitors the client carefully for which complication of ARDS? Blood clots Multiorgan system failure Vision loss Hearing impairment

Multiorgan system failure Rationale: The client with ARDS is at risk for developing multiorgan system failure related to ineffective tissue oxygenation including kidney failure, liver failure, gastrointestinal failure, central nervous system failure, and cardiovascular failure. Blood clots, vision loss, and hearing impairment are not hallmarks of ARDS or multiorgan system failure.

A 12-year-old is being treated for acute respiratory distress syndrome. Which assessment finding would be indicative of the nursing diagnosis of impaired gas exchange? Heart rate of 100 bpm Oxygen saturation of 62% Respiratory rate of 60/min Bicarbonate level of 38 mEq/L

Oxygen saturation of 62% Rationale: Normal levels of oxygen saturation are 95-100%. The client with an O2 level of 62% is not exchanging gases. Heart rate increase is a sign of many disorders and by itself does not signify impaired gas exchange. A respiratory rate of 60 signifies respiratory distress but does not imply impaired gas exchange. Bicarbonate levels are an indication of kidney function.

The nurse caring for a client undergoing mechanical ventilation for acute respiratory distress syndrome (ARDS) plans which of the following interventions to help maintain effective alveolar ventilation? Keeps the client in a supine position Performs endotracheal suctioning as indicated Maintains ordered oxygen concentration Increases the tidal volume on the ventilator

Performs endotracheal suctioning as indicated Rationale: Patent airways are necessary to maintain effective alveolar ventilation and gas exchange. Keeping the client in a supine position does not promote a patent airway. If the airway is full of secretions, increasing tidal volume and maintaining oxygen concentration are not helpful in keeping the airway patent.