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 C

Explanation

A. A client who has a red rash over his abdomen: A red rash may indicate an allergic reaction or viral infection, but it is not life-threatening. This client would be considered a lower priority compared to those with life-threatening conditions.

B. A client who has multiple fractures: Multiple fractures may be serious but they do not constitute an immediate threat to life unless there is significant blood loss or organ damage. This client would be categorized as urgent not emergent unless accompanied by complications like shock.

C. A client who has a punctured femoral artery: A punctured femoral artery is an emergent situation because it involves massive blood loss. Hemorrhage from this major artery can quickly lead to shock and death if not treated immediately.

D. A client who reports severe flank pain radiating to the groin: Severe flank pain, especially radiating to the groin, is suggestive of renal colic or kidney stones, which, while extremely painful, are not life-threatening in an emergency context.

A. Administer enteric-coated acetaminophen with milk B. Maintain oxygen saturations greater than or equal to 92% C. Assess an EKG for ST changes D. Administer ibuprofen with food

Correct Answer is C

Explanation

A. Administer enteric-coated acetaminophen with milk: The symptoms of jaw, back, shoulder pain, and shortness of breath are concerning for a myocardial infarction. Immediate assessment with an EKG is needed, not pain management with acetaminophen.

B. Maintain oxygen saturations greater than or equal to 92%: While maintaining oxygen saturation is important, the priority is to assess for signs of myocardial infarction via an EKG. Cardiac ischemia should be identified first, and oxygen support is part of further treatment.

C. Assess an EKG for ST changes: Symptoms like pain and shortness of breath are classic signs of a heart attack. An EKG will show any ST elevation or depression, guiding necessary interventions such as medication or procedures for ischemia.

D. Administer ibuprofen with food: Ibuprofen is not the first-line treatment for chest pain associated with a possible heart attack. Immediate action should focus on diagnosing potential ischemia through an EKG and providing appropriate cardiac care.

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