Unit 2 (sen 4) ARDS/IRDS
What clinical indicators should a nurse expect to identify in a client with acute respiratory distress syndrome (ARDS)? Select all that apply. 1 Crackles 2 Atelectasis 3 Hypoxemia 4 Severe dyspnea 5 Increased pulmonary wedge pressure
Crackles, atelectasis, hypoxemia, & severe dyspnea Rationale Crackles occur as fluid leaks into the alveolar interstitial space. The alveoli collapse from surfactant dysfunction and infiltrate from inflammation. Arterial hypoxemia that does not respond to supplemental oxygen is a characteristic sign of ARDS. Severe dyspnea can occur 12 to 48 hours after the initial onset of ARDS, which usually is an inflammatory trigger. Pulmonary wedge pressure is unaffected in ARDS; pulmonary wedge pressure is elevated in problems with cardiogenic origin.
A client develops acute respiratory distress, and a tracheostomy is performed. Which intervention is most important for the nurse to implement when caring for this client? 1 Encouraging a fluid intake of 3 L daily 2 Suctioning via the tracheostomy every hour 3 Applying an occlusive dressing over the surgical site 4 Using cotton balls to cleanse the stoma with peroxide
Encouraging a fluid intake of 3 L daily Rationale Increased fluids help to liquefy secretions, enabling the client to clear the respiratory tract by coughing. Suctioning frequently will irritate the mucosal lining of the respiratory tract, which can result in more secretions. An occlusive dressing will block air exchange; the tracheostomy is now the client's airway. The use of cotton balls around a tracheostomy introduces the risk of aspiration of one of the cotton fibers; gauze should be used.
In addition to treatment of the underlying cause, which medical intervention should the nurse anticipate will be included in the management of a client with acute respiratory distress syndrome (ARDS)? 1 Chest tube insertion 2 Aggressive diuretic therapy 3 Administration of beta-blockers 4 Positive end-expiratory pressure (PEEP)
Positive end-expiratory pressure (PEEP) Rationale Mechanical ventilation with PEEP will help prevent alveolar collapse and improve oxygenation. Fluid is not in the pleural space, so chest tube insertion is not indicated. Aggressive diuretic therapy and administration of beta-blockers are contraindicated because of severe hypotension from the fluid shift into the interstitial spaces in the lungs.
A client with acute respiratory distress syndrome is intubated and placed on a ventilator. What should the nurse do when caring for this client and the mechanical ventilator? 1 Deflate the cuff on the endotracheal tube for a few minutes every one to two hours. 2 Assess the need for suctioning when the high-pressure alarm of the ventilator is activated. 3 Adjust the temperature of fluid in the humidification chamber depending on the volume of gas delivered. 4 Regulate the positive end-expiratory pressure (PEEP) according to the rate and depth of the client's respirations.
Assess the need for suctioning when the high-pressure alarm of the ventilator is activated. Rationale The high-pressure alarm signifies increased pressure in the tubing or the respiratory tract; obstruction usually is caused by excessive secretions. Cuff should be inflated; it does not need to be tested this often. Humidification should occur, but the temperature should not be routinely changed. Regulating the PEEP according to the rate and depth of the client's respirations is a dependent function of the nurse and cannot be implemented without a healthcare provider's prescription.
A client is admitted to the intensive care unit with a diagnosis of acute respiratory distress syndrome. Which clinical finding should the nurse expect when assessing this client? 1 Hypertension 2 Tenacious sputum 3 Altered mental status 4 Slowed rate of breathing
Altered mental status Rationale Altered mental status is secondary to cerebral hypoxia, which accompanies acute respiratory distress syndrome (ARDS); cognition and level of consciousness are reduced. Hypotension occurs because of cardiac hypoxia. The sputum is not tenacious, but it may be frothy if pulmonary edema is present. Breathing is fast and shallow.
A nurse is caring for several clients in the intensive care unit. Which is the greatest risk factor for a client to develop acute respiratory distress syndrome (ARDS)? 1 Aspirating gastric contents 2 Getting an opioid overdose 3 Experiencing an anaphylactic reaction 4 Receiving multiple blood transfusions
Aspirating gastric contents Rationale Aspirating gastric contents is a common cause of ARDS. Gastric enzymes injure alveolar-capillary membranes, which release inflammatory mediators; the process progresses to pulmonary edema, vascular narrowing and obstruction, pulmonary hypertension, and impaired gas exchange. Getting an opioid overdose is not as common a cause of ARDS as is aspiration pneumonia; this more likely will cause depressed respirations. Although anaphylaxis may cause ARDS, it is not a common cause. Although multiple blood transfusions have been known to precipitate ARDS, they are not a common cause.
After surgery, a client is extubated in the postanesthesia care unit. Which clinical manifestations should the nurse expect if the client is experiencing acute respiratory distress? Select all that apply. 1 Confusion 2 Hypocapnia 3 Tachycardia 4 Constricted pupils 5 Slow respiratory rate
Confusion & tachycardia Rationale Inadequate cerebral oxygenation produces restlessness and confusion. Tachycardia occurs as the body attempts to compensate for the lack of oxygen. A low carbon dioxide level in the blood (hypocapnia) occurs with hyperventilation, not hypoxia. The pupils dilate, not constrict, with hypoxia. An elevated respiratory rate (tachypnea), not a slow respiratory rate (bradypnea), occurs.
A client with a history of emphysema is admitted with a diagnosis of acute respiratory failure with respiratory acidosis. Oxygen is being administered at 3 L/min nasal cannula. Four hours after admission, the client has increased restlessness and confusion followed by a decreased respiratory rate and lethargy. What should the nurse do? 1 Question the client about the confusion. 2 Change the method of oxygen delivery. 3 Percuss and vibrate the client's chest wall. 4 Discontinue or decrease the oxygen flow rate.
Duscontinue or decrease the oxygen flow rate Rationale With emphysema, it is believed that the respiratory center no longer responds to elevated carbon dioxide as the stimulus to breathe [1] [2] but rather to lowered oxygen levels; therefore, the oxygen being delivered must be lowered to supply enough for oxygenation without being so elevated that it negates the stimulus to breathe. However, the results of one recent study of clients with stable chronic obstructive pulmonary disease (COPD) indicate that the hypercarbic drive is preserved. More research is needed before this theory is applied clinically. A confused client cannot answer questions about the confusion. There are no indications that respiratory secretions have increased.
A client with late-stage dementia of the Alzheimer type aspirates gastric contents and develops acute respiratory distress syndrome (ARDS). Which phase characterized by signs of pulmonary edema and atelectasis should the nurse consider when planning care? 1 Fibrotic 2 Exudative 3 Reparative 4 Proliferative
Exudative Rationale Exudative (injury) phase of ARDS is the early phase. Alveoli become fluid-filled with pulmonary shunting and atelectasis. Fibrotic phase of ARDS leads to pulmonary hypertension and fibrosis. Reparative (resolution) phase starts about two weeks after injury; it is characterized by recovery. If this phase persists for a prolonged time, extensive fibrosis, death, or chronic disease may result.
A nurse is caring for a toddler in acute respiratory distress precipitated by laryngotracheobronchitis. The child has a temperature of 103° F (39.4° C). What is the priority nursing intervention? 1 Delivering humidified oxygen 2 Initiating measures to reduce fever 3 Monitoring respiratory status continuously 4 Providing support to diminish apprehension
Monitoring respiratory status continuously Rationale Laryngeal spasms can occur abruptly; patency of the airway is determined through continuous monitoring for signs of respiratory distress. Providing oxygen is important, but maintenance of respiration is the priority. The fever should be treated, but it is not critical at 103° F (39.4° C); maintenance of respiration is the priority. Offering support is important, but maintenance of respiration is the priority.
A toddler who was admitted in acute respiratory distress is now resting quietly. The parents tell the nurse that they must leave. What should the nurse suggest that the parents do?
Plan to visit the child as frequently as possible Rationale Because the parents have stated that they must leave, advising them to visit as often as possible takes into consideration the effect that separation will have on the toddler. Suggesting that the parents "room in," or stay in the room with the child, when they have already stated that they must leave may create a sense of guilt or feelings of inadequacy in the parents. Telling the parents to tell the child that they are leaving but will be back tomorrow is inappropriate because a 2-year-old does not understand the concept of time. Leaving when the child is distracted will jeopardize the child's sense of trust in the parents.
A client with a 10-year history of emphysema is admitted in acute respiratory distress. During assessment, what does the nurse expect to identify? 1 Chest pain on inspiration 2 Prolonged expiration with use of accessory muscles 3 Signs and symptoms of respiratory alkalosis 4 Decreased respiratory rate
Prolonged expiration with use of accessory muscles Rationale Accessory muscles are used during respiration because of the increased rigidity of the chest. Sudden pleuritic chest pain is associated with pulmonary embolism, not emphysema. Respiratory acidosis, not alkalosis, is associated with emphysema because of carbon dioxide retention. Clients with respiratory muscle fatigue breathe with rapid, shallow respirations.
A client is extubated in the postanesthesia care unit after surgery. For which common response should the nurse be alert when monitoring the client for acute respiratory distress? 1 Bradycardia 2 Restlessness 3 Constricted pupils 4 Clubbing of the fingers
Restlessness Rationale Inadequate oxygenation of the brain from acute respiratory distress may produce restlessness or behavioral changes. The pulse increases with cerebral hypoxia from acute respiratory distress. The pupils dilate with cerebral hypoxia. Clubbing of the fingers is the result of prolonged hypoxia.
An emergency tracheotomy is performed on a toddler in acute respiratory distress from laryngotracheobronchitis (viral croup). What early signs of respiratory distress indicate that it is necessary for the nurse to suction the tracheotomy? Select all that apply. 1 Stridor 2 Cyanosis 3 Restlessness 4 Increased pulse rate 5 Substernal retractions
Restlessness & increased pulse rate Rationale Restlessness and increased pulse rate are early signs of hypoxia; suctioning is required to keep the airway patent. Stridor, cyanosis, and substernal retractions are late signs of hypoxia; suctioning should be performed before substernal retractions occur.
When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse would implement which measure to promote effective airway clearance? 1 Administer sedatives around the clock 2 Turn client every four hours 3 Increase ventilator settings as needed 4 Suction as needed
Suction as needed Rationale The nurse should observe the client's need for tracheal/oral/nasal suctioning every two hours and provide adequate suctioning as needed. The nurse should not administer sedatives around the clock, but administer sedatives as appropriate. The nurse should turn the client every two hours, not four hours. The nurse should not adjust vent settings as needed; however, the nurse should check ventilation settings at least once a shift.