A nurse is caring for a patient with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation using synchronized intermittent mandatory ventilation (SIMV). The settings include fraction of inspired oxygen (FIO2) of 80%, tidal volume of 450, rate of 16/minute, and positive end- expiratory pressure (PEEP) of 5 cm. Which assessment finding is most important for the nurse to report to the health care provider?

Respiratory rate 22 breaths/min

Heart rate 106 beats/min

02 saturation of 99%

Crackles audible at lung bases

Answer and Explanation

The Correct Answer is D

D Crackles audible at the lung bases indicate the presence of pulmonary edema or fluid accumulation in the alveoli, which can compromise gas exchange and exacerbate respiratory distress. In a patient with ARDS, crackles suggest worsening pulmonary status and may indicate inadequate ventilation or oxygenation despite mechanical ventilation. Therefore, crackles at the lung bases are the most important finding to report to the healthcare provider as they may indicate a need for adjustments to the ventilator settings or additional interventions to optimize respiratory function and prevent further deterioration.

A respiratory rate of 22 breaths/min may be within an acceptable range, particularly considering that the patient is receiving mechanical ventilation. However, any significant deviation from the baseline respiratory rate or signs of respiratory distress, such as increased work of breathing or accessory muscle use, should be closely monitored and reported promptly.

B A heart rate of 106 beats/min may be within an acceptable range, although it is slightly elevated. Tachycardia can occur due to various factors, including pain, anxiety, fever, or hypoxemia. While tachycardia warrants close monitoring, it may not be the most critical finding to report unless it is associated with hemodynamic instability or other concerning symptoms.

C An oxygen saturation of 99% indicates adequate oxygenation, which is reassuring, particularly in a patient with acute respiratory distress syndrome (ARDS). However, oxygen saturation alone may not reflect the adequacy of ventilation or the severity of the underlying lung injury. Therefore, while oxygen saturation should be monitored closely, it may not be the most critical finding to report unless it declines significantly or is accompanied by other concerning symptoms.

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Correct Answer is C

Explanation

C. Hypovolemia, or low blood volume, can lead to decreased venous return to the heart and reduced filling pressures. Consequently, CVP may decrease in hypovolemic states. Low CVP may indicate inadequate preload and reduced cardiac output, which are characteristic of hypovolemia.

A. Left ventricular failure typically results in elevated filling pressures rather than low CVP. In left ventricular failure, blood backs up into the pulmonary circulation, leading to increased pulmonary venous pressure and potentially elevated pulmonary capillary wedge pressure (PCWP), which is a surrogate marker for left atrial pressure. This elevated pressure is reflected in the CVP as well, resulting in increased CVP rather than low CVP.

B. Fluid overload typically results in elevated filling pressures and increased CVP rather than low CVP. Excess fluid volume increases venous return to the heart, leading to increased pressure within the central veins and elevated CVP.

D. Intracardiac shunts may cause alterations in cardiac pressures, but they typically do not result in consistently low CVP. Depending on the type and severity of the shunt, the direction and magnitude of pressure changes may vary. However, in the absence of other pathophysiological factors, intracardiac shunts are less likely to cause consistently low CVP.

A. Prone Position B. Positioning supine with head elevated to 30-45 degrees C. Infusion of Albumin D. Transfusion of PRBC

Correct Answer is A

Explanation

A. Prone positioning involves turning the patient onto their abdomen to improve ventilation-perfusion matching by redistributing ventilation to the dorsal lung regions, where perfusion is typically better in ARDS patients.

B. Semi-recumbent positioning may be used to prevent aspiration and reduce the risk of VAP but is not as effective as prone positioning for improving V/Q matching.

C. Albumin infusion is not specific interventions for improving ventilation-perfusion matching in ARDS and should be considered based on other clinical indications.

D. Transfusion of packed red blood cells (PRBC) may be indicated in cases of severe anemia or hypoxemia due to inadequate oxygen-carrying capacity. However, it is not a primary intervention for improving ventilation-perfusion matching in ARDS

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Naxlex Comprehensive Predictor Exams

A nurse is evaluating the central venous pressure (CVP) of a client who has sustained multiple traumas. Which of the following interpretations of a low CVP pressure should the nurse make?

Correct Answer is C

Explanation

A client with acute respiratory distress syndrome (ARDS) shows no improvement despite increases in concentration in oxygen administered. What intervention should the nurse attempt which may improve ventilation-perfusion matching?

Correct Answer is A

Explanation

Which information about a patient who is receiving cisatracurium (Nimbex) to prevent asynchronous breathing with the positive pressure ventilator requires action by the nurse?

A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?

A nurse is interpreting a client's ECG strip. Which of the following components of the ECG should the nurse examine to determine the time it takes for ventricular depolarization and repolarization?

Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the patient's caregiver is accurate?

A nurse is preparing a client for transfer to the ICU for placement of a pulmonary artery catheter. The nurse should explain to the client that this catheter is used to monitor which of the following conditions?

A nurse is caring for a client who is in the compensatory stage of shock. Which of the following findings should the nurse expect?

A nurse is caring for a client who reports heart palpitations. An ECG confirms the client is experiencing ventricular tachycardia (VT). The nurse should anticipate the need for taking which of the following actions?

A nurse is caring for a client who has an acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply.)