A client admitted for difficulty breathing becomes worse. Which assessment findings indicate that the client has developed acute respiratory distress syndrome (ARDS)? Select all that apply

Sub-sternal chest pressure

02 sats at 75% on 100% Fi02

Anxiety and restlessness

Increasing dyspnea

Pitting edema to ankles

Answer and Explanation

Correct Answer : B,C,D

A. Sub-sternal chest pressure: Sub-sternal chest pressure can be a sign of cardiac issues such as angina or myocardial infarction, not typically seen with ARDS. ARDS primarily involves respiratory symptoms such as severe hypoxemia and increasing dyspnea.

B. O2 sats at 75% on 100% Fi02: A significant decrease in oxygen saturation despite 100% oxygen administration is a hallmark sign of ARDS. This condition is characterized by severe, refractory hypoxemia, where the lungs are unable to provide adequate oxygen to the bloodstream even with high levels of oxygen.

C. Anxiety and restlessness: Anxiety and restlessness are common in ARDS due to hypoxia and respiratory distress. As the body struggles to get sufficient oxygen, the client may experience increased anxiety, restlessness, and discomfort, which are signs of worsening respiratory function.

D. Increasing dyspnea: Increasing dyspnea, or difficulty breathing, is a classic symptom of ARDS. As the condition progresses, the client’s ability to breathe becomes more labored due to inflammation and fluid buildup in the alveoli, leading to worsening oxygenation.

E. Pitting edema to ankles: Pitting edema to the ankles is more commonly associated with heart failure or fluid retention rather than ARDS. ARDS typically causes fluid buildup in the lungs rather than peripheral edema, which occurs in cases of circulatory problems.

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Correct Answer is A

Explanation

A. Tachycardia: In the early stages of hypoxia, the body compensates for low oxygen levels by increasing the heart rate (tachycardia) to improve oxygen delivery to tissues. Tachycardia is one of the first signs of hypoxia as the cardiovascular system tries to compensate.

B. Bradypnea: Bradypnea, or slow breathing, is not typically seen in early hypoxia. Instead, hypoxia usually causes tachypnea (rapid breathing) as the body attempts to increase oxygen intake. Bradypnea is more likely to occur in severe hypoxia or respiratory failure.

C. Somnolence: Somnolence (drowsiness) may occur as hypoxia worsens, but it is not typically an early sign. In the early stages of hypoxia, the body compensates by increasing the heart rate and breathing rate, rather than causing drowsiness.

D. Pallor: Pallor can occur in hypoxia due to reduced oxygenation of the skin, but it is not one of the earliest signs. Tachycardia and increased respiratory rate are more common initial responses to hypoxia. Pallor tends to be seen as hypoxia progresses.

A. Blockage of the ET tube by the client's tongue B. Infection of the vocal cords C. Passage of the ET tube into the esophagus D. Movement of the ET tube into the right main bronchus

Correct Answer is D

Explanation

A. Blockage of the ET tube by the client's tongue: If the ET tube is blocked by the tongue, the nurse would expect difficulty breathing or noisy respirations, not asymmetric chest wall expansion. This issue would typically affect both sides of the chest, not just one side.

B. Infection of the vocal cords: Infection of the vocal cords can lead to hoarseness or difficulty with speech but would not cause asymmetric chest wall expansion. The physical sign of unequal chest expansion is more related to airway placement or obstruction.

C. Passage of the ET tube into the esophagus: If the ET tube were in the esophagus, it would obstruct airflow entirely, leading to no chest expansion on either side and no air exchange. The observed asymmetry suggests partial blockage or malposition of the ET tube.

D. Movement of the ET tube into the right main bronchus: If the ET tube has moved into the right main bronchus, it would primarily ventilate the right lung, leading to absent expansion on the left side. This occurs because the tube is no longer in the trachea but in a more lateral position, ventilating only the right lung.

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A client admitted for difficulty breathing becomes worse. Which assessment findings indicate that the client has developed acute respiratory distress syndrome (ARDS)? Select all that apply

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is in the early stages of hypoxia. Which of the following assessment findings should the nurse expect?

Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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