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A nurse is assessing a client who is suspected of having ARDS. The nurse is confused that although the client appears dyspneic and the oxygen saturation is 88% on 6 L/min of oxygen, the client's lungs are clear. What explanation does the more senior nurse provide?

A.

"The client is too dehydrated for moist-sounding lungs.

B.

"The client has not started having any bronchospasms yet."

C.

"Clients on oxygen have clear lung sounds."

D.

"Lung edema is in the interstitial tissues, not the airways."

Answer and Explanation

The Correct Answer is D

Rationale:
A. "The client is too dehydrated for moist-sounding lungs." is incorrect because dehydration does not explain clear lung sounds in ARDS. ARDS involves fluid accumulation in the lungs, but the early stages do not always produce crackles or wheezes, regardless of hydration status.

B. "The client has not started having any bronchospasms yet." is incorrect because bronchospasms are characteristic of asthma or COPD, not ARDS. ARDS is primarily a non-cardiogenic pulmonary edema caused by increased permeability of the alveolar-capillary membrane, not airway constriction.

C. "Clients on oxygen have clear lung sounds." is incorrect because oxygen therapy does not affect whether lung sounds are clear or abnormal. Oxygen improves oxygenation, but it does not change the physical presence of alveolar or interstitial fluid.

D. "Lung edema is in the interstitial tissues, not the airways." is correct because in early ARDS, fluid accumulates in the interstitial and alveolar spaces rather than the larger airways. This interstitial edema does not always produce abnormal breath sounds, even though the patient is hypoxemic and dyspneic. As ARDS progresses, alveolar flooding may produce crackles and decreased lung compliance, but early ARDS can have clear lung auscultation despite severe hypoxemia.


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Related Questions

Correct Answer is B

Explanation

Rationale:

  1. 2 mm Hg – Far too low and does not match the calculation.
  2. 90 mm Hg –Matches the calculation (MAP − ICP).

Given:

  • MAP = 108 mm Hg
  • ICP = 18 mm Hg

Calculation:
CPP = 108 − 18
CPP = 90 mm Hg

A CPP of 70–100 mm Hg is generally considered adequate to maintain cerebral perfusion in adults. Values below 60 mm Hg can result in cerebral ischemia

C. 126 mm Hg – This would be MAP + ICP, which is not correct for CPP.
D. 54 mm Hg – Likely results from an incorrect calculation.
Cerebral perfusion pressure (CPP) is calculated using the formula: CPP = MAP − ICP.

Correct Answer is D

Explanation

Rationale:
A. This is incorrect because hand hygiene is the most critical intervention to prevent infection in immunosuppressed patients. Staff should strictly wash hands before and after all patient contact. Omitting hand washing would increase the risk of life-threatening infections.

B. This is incorrect because antimicrobial soaps are safe and often recommended for bathing immunosuppressed patients to reduce the risk of infection. Avoiding them could increase susceptibility to pathogens.

C. This is incorrect because placing multiple intravenous lines unnecessarily increases the risk of infection and does not prevent immunosuppression-related complications. IV lines should only be used as clinically indicated.

D. This is correct because placing the patient in a single room with HEPA filtration helps reduce exposure to airborne pathogens, which is essential for severely immunocompromised patients, such as those undergoing chemotherapy. Additional precautions include limiting visitors, using protective equipment, and maintaining strict aseptic technique during procedures.

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