ACUTE RESP DISTRESS SYNDROME (ARDS) Answered with Complete Rationales 100% all correct!

ACUTE RESP DISTRESS SYNDROME (ARDS) Answered with Complete Rationales 100% all correct! ACUTE RESP DISTRESS SYNDROME (ARDS) 1. The unlicensed assistive personnel (UAP) is bathing the client diagnosed with acute respiratory distress syndrome (ARDS). The bed is in a high position with the opposite side rail in the low position. Which action should the nurse implement? 1. Demonstrate the correct technique for giving a bed bath.** 2. Encourage the UAP to put the bed in the lowest position. 3. Instruct the UAP to get another person to help with the bath. 4. Provide praise for performing the bath safely for the client and the UAP. 2. The client diagnosed with ARDS is transferred to the intensive care department and placed on a ventilator. Which intervention should the nurse implement first? 1. Confirm that the ventilator settings are correct. 2. Verify that the ventilator alarms are functioning properly. 3. Assess the respiratory status and pulse oximeter reading.** 4. Monitor the client’s arterial blood gas results. 3. The nurse suspects the client may be developing ARDS. Which assessment data confirm the diagnosis of ARDS? 1. Low arterial oxygen when administering high concentration of oxygen.** 2. The client has dyspnea and tachycardia and is feeling anxious. 3. Bilateral breath sounds clear and pulse oximeter reading is 95%. 4. The client has jugular vein distention and frothy sputum. 4. The client who smokes two (2) packs of cigarettes a day develops ARDS after a near-drowning. The client asks the nurse, “What is happening to me? Why did I get this?” Which statement by the nurse is most appropriate? 1. “Most people who almost drown end up developing ARDS.” 2. “Platelets and fluid enter the alveoli due to permeability instability.” 3. “Your lungs are filling up with fluid, causing breathing problems.”** 4. “Smoking has caused your lungs to become weakened, so you got ARDS.” 5. Which assessment data indicate to the nurse the client diagnosed with ARDS has experienced a complication secondary to the ventilator? 1. The client’s urine output is 100 mL in four (4) hours. 2. The pulse oximeter reading is greater than 95%. 3. The client has asymmetrical chest expansion.** 4. The telemetry reading shows sinus tachycardia. 6. The health-care provider ordered STAT arterial blood gases (ABGs) for the client diagnosed with ARDS. The ABG results are pH 7.38, PaO2 92, PaCO2 38, HCO3 24. Which action should the nurse implement? 1. Continue to monitor the client without taking any action.** 2. Encourage the client to take deep breaths and cough. 3. Administer one (1) ampule of sodium bicarbonate IVP. 4. Notify the respiratory therapist of the ABG results. 7. The client with ARDS is on a mechanical ventilator. Which intervention should be included in the nursing care plan addressing the endotracheal tube care? 1. Do not move or touch the ET tube. 2. Obtain a chest x-ray daily. 3. Determine if the ET cuff is deflated. 4. Ensure that the ET tube is secure.** 8. Which medication should the nurse anticipate the health-care provider ordering for the client diagnosed with ARDS? 1. An aminoglycoside antibiotic. 2. A synthetic surfactant.** 3. A potassium cation. 4. A nonsteroidal anti-inflammatory drug. 9. The client diagnosed with ARDS is in respiratory distress and the ventilator is malfunctioning. Which intervention should the nurse implement first? 1. Notify the respiratory therapist immediately. 2. Ventilate with a manual resuscitation bag.** 3. Request STAT arterial blood gases. 4. Auscultate the client’s lung sounds. 10. The nurse is caring for the client diagnosed with ARDS. Which interventions should the nurse implement? Select all that apply. 1. Assess the client’s level of consciousness.** 2. Monitor urine output every shift. 3. Turn the client every two (2) hours.** 4. Maintain intravenous fluids as ordered.** 5. Place the client in the Fowler’s position.** 11. Which instruction is priority for the nurse to discuss with the client diagnosed with ARDS who is being discharged from the hospital? 1. Avoid smoking and exposure to smoke.* 2. Do not receive flu or pneumonia vaccines. 3. Avoid any type of alcohol intake. 4. It will take about one (1) month to recuperate. 12. The client diagnosed with ARDS is on a ventilator and the high alarm indicates an increase in the peak airway pressure. Which intervention should the nurse implement first? 1. Check the tubing for any kinks.* 2. Suction the airway for secretions. 3. Assess the lip line of the ET tube. 4. Sedate the client with a muscle relaxant 13. When explaining respiratory failure to the patient’s family, what should the nurse use as an accurate description? a. The absence of ventilation b. Any episode in which part of the airway is obstructed c. Inadequate gas exchange to meet the metabolic needs of the body d. An episode of acute hypoxemia caused by a pulmonary dysfunction . c. Respiratory failure results when the transfer of oxygen or carbon dioxide function of the respiratory system is impaired and, although the definition is determined by PaO2 and PaCO2 levels, the major factor in respiratory failure is inadequate gas exchange to meet tissue oxygen (O2) needs.Absence of ventilation is respiratory arrest and partial airway obstruction may not necessarily cause respiratory failure. Acute hypoxemia may be caused by factors other than pulmonary dysfunction. 14. When teaching the patient about what was happening when experiencing an intrapulmonary shunt, which explanation is accurate? a. This occurs when an obstruction impairs the flow of blood to the ventilated areas of the lung. b. This occurs when blood passes through an anatomic channel in the heart and bypasses the lungs. c. This occurs when blood flows through the capillaries in the lungs without participating in gas exchange. d. Gas exchange across the alveolar capillary interface is compromised by thickened or damaged alveolar membranes. . c. Intrapulmonary shunt occurs when blood flows through the capillaries in the lungs without participating in gas exchange (e.g., acute respiratory distress syndrome [ARDS], pneumonia). Obstruction impairs the flow of blood to the ventilated areas of the lung in a V/Q mismatch ratio greater than 1 (e.g., pulmonary embolus). Blood passes through an anatomic channel in the heart and bypasses the lungs with anatomic shunt (e.g., ventricular septal defect). Gas exchange across the alveolar capillary interface is compromised by thickened or damaged alveolar membranes in diffusion limitation (e.g., pulmonary fibrosis, ARDS). 15. When the V/Q lung scan result returns with a mismatch ratio that is greater than 1, which condition should be suspected? a. Pain b. Atelectasis c. Pulmonary embolus d. Ventricular septal defect c. There will be more ventilation than perfusion (V/Q ratio greater than 1) with a pulmonary embolus. Pain and atelectasis will cause a V/Q ratio less than 1. A ventricular septal defect causes an anatomic shunt as the blood bypasses the lungs. 16. Which physiologic mechanism of hypoxemia occurs with pulmonary fibrosis? a. Anatomic shunt c. Intrapulmonary shunt b. Diffusion limitation d. V/Q mismatch ratio of less than 1 . b. Diffusion limitation in pulmonary fibrosis is caused by thickened alveolar-capillary interface, which slows gas transport. 17. Which assessment finding should cause the nurse to suspect the early onset of hypoxemia? a. Restlessness c. Central cyanosis b. Hypotension d. Cardiac dysrhythmias a. Because the brain is very sensitive to a decrease in oxygen delivery, restlessness, agitation, disorientation, and confusion are early signs of hypoxemia, for which the nurse should be alert. Mild hypertension is also an early sign, accompanied by tachycardia. Central cyanosis is an unreliable, late sign of hypoxemia. Cardiac dysrhythmias also occur later. 18. The nurse assesses that a patient in respiratory distress is developing respiratory fatigue and the risk of respiratory arrest when the patient displays which behavior? a. Cannot breathe unless he is sitting upright b. Uses the abdominal muscles during expiration c. Has an increased inspiratory-expiratory (I/E) ratio d. Has a change in respiratory rate from rapid to slow d. The increase in respiratory rate required to blow off accumulated CO2 predisposes to respiratory muscle fatigue. The slowing of a rapid rate in a patient in acute distress indicates tiring and the possibility of respiratory arrest unless ventilatory assistance is provided. A decreased inspiratory-expiratory (I/E) ratio, orthopnea, and accessory muscle use are common findings in respiratory distress but do not necessarily signal respiratory fatigue or arrest. 19. A patient has a PaO2 of 50 mm Hg and a PaCO2 of 42 mm Hg because of an intrapulmonary shunt. Which therapy is the patient most likely to respond best to? a. Positive pressure ventilation b. Oxygen administration at a FIO2 of 100% c. Administration of O2 per nasal cannula at 1 to 3 L/min d. Clearance of airway secretions with coughing and suctioning a. Patients with a shunt are usually more hypoxemic than patients with a V/Q mismatch because the alveoli are filled with fluid, which prevents gas exchange. Hypoxemia resulting from an intrapulmonary shunt is usually not responsive to high O2 concentrations and the patient will usually require positive pressure ventilation. Hypoxemia associated with a V/Q mismatch usually responds favorably to O2 administration at 1 to 3 L/min by nasal cannula. Removal of secretions with coughing and suctioning is generally not effective in reversing an acute hypoxemia resulting from a shunt. 20. A patient with a massive hemothorax and pneumothorax has absent breath sounds in the right lung. To promote improved V/Q matching, how should the nurse position the patient? a. On the left side b. On the right side c. In a reclining chair bed d. Supine with the head of the bed elevated a. When there is impaired function of one lung, the patient should be positioned with the unaffected lung in the dependent position to promote perfusion to the functioning tissue. If the diseased lung is positioned dependently, more V/Q mismatch would occur. The head of the bed may be elevated or a reclining chair may be used, with the patient positioned on the unaffected side, to maximize thoracic expansion if the patient has increased work of breathing. 21. Priority Decision: After endotracheal intubation and mechanical ventilation have been started, a patient in respiratory failure becomes very agitated and is breathing asynchronously with the ventilator. What is it most important for the nurse to do first? a. Evaluate the patient’s pain level, ABGs, and electrolyte values b. Sedate the patient to unconsciousness to eliminate patient awareness c. Administer the PRN vecuronium (Norcuron) to promote synchronous ventilations