A nurse is caring for a client who has developed acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse identify as a manifestation of this syndrome?

An audible pleural friction rub

Tracheal deviation from the midline

Refractory hypoxemia

Bloody expectorant when coughing

Answer and Explanation

The Correct Answer is C

Rationale:
A. An audible pleural friction rub: A pleural friction rub is typically heard in conditions involving pleural inflammation, such as pleurisy or pericarditis. It is not a defining feature of acute respiratory distress syndrome, which primarily involves alveolar damage and pulmonary edema.

B. Tracheal deviation from the midline: Tracheal deviation is usually associated with a tension pneumothorax or large pleural effusion. ARDS does not typically cause tracheal shift, as it affects the lungs diffusely rather than exerting pressure on one side.

C. Refractory hypoxemia: This is a hallmark of ARDS. It refers to hypoxemia that does not improve significantly with supplemental oxygen due to impaired gas exchange from widespread alveolar-capillary membrane damage, leading to severe ventilation-perfusion mismatch.

D. Bloody expectorant when coughing: Hemoptysis (bloody sputum) can occur in various respiratory conditions but is not a characteristic manifestation of ARDS. In ARDS, secretions are more likely to be frothy and pink-tinged if pulmonary edema is present.

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Correct Answer is A

Explanation

Rationale:
A. Report of itching: Itching is a common early sign of an allergic transfusion reaction. These reactions occur due to sensitivity to plasma proteins in the donor blood and may also present with hives, flushing, or mild respiratory symptoms.

B. Distended jugular veins: Jugular vein distention is a sign of fluid overload or circulatory compromise, such as transfusion-associated circulatory overload (TACO), not an allergic reaction.

C. Report of low back pain: Low back pain is more indicative of an acute hemolytic reaction, which results from ABO incompatibility. This is a serious and life-threatening reaction distinct from allergic responses.

D. Temperature 37.8° C (100° F): A mild elevation in temperature may be seen with febrile non-hemolytic transfusion reactions, which are different from allergic reactions. Allergic reactions usually involve skin and respiratory symptoms.

A. "Use the clean technique when suctioning." B. "Clean the stoma site with full-strength hydrogen peroxide." C. "Decrease the humidity level in your home." D. "Remove soiled tracheostomy ties before replacing them."

Correct Answer is A

Explanation

Rationale:
A. "Use the clean technique when suctioning.": For a well-established tracheostomy (typically after 1 month), clean technique is acceptable for suctioning at home. This reduces infection risk while allowing practical self-care or family-provided care in a non-sterile environment.

B. "Clean the stoma site with full-strength hydrogen peroxide.": Full-strength hydrogen peroxide is too harsh and can damage healthy tissue. A diluted solution or normal saline is safer for routine stoma care to avoid irritation and promote healing.

C. "Decrease the humidity level in your home.": Adequate humidity is essential for clients with tracheostomies to keep secretions thin and prevent airway blockage. Low humidity can dry the airway and increase the risk of mucus plugs.

D. "Remove soiled tracheostomy ties before replacing them.": Tracheostomy ties should be replaced one side at a time to prevent accidental decannulation. Removing both sides at once leaves the tracheostomy tube unsecured and poses a serious safety risk.

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