A patient with Acute Respiratory Distress Syndrome is mechanically ventilated. Coarse crackles are heard over upper airways, the SaO2 has dropped to 85%, and the patient is agitated. Which action should the nurse take?

Obtain an order for a chest x-ray.

Increase the PEEP.

Perform endotracheal suctioning.

Reposition the patient.

Answer and Explanation

The Correct Answer is C

Choice A reason:

While obtaining a chest x-ray can help assess the patient's condition, it is not the immediate action needed in this situation. The patient's drop in SaO2 and agitation indicate an acute issue that needs to be addressed promptly.

Choice B reason:

Increasing the PEEP might help improve oxygenation, but it is not the first action to take. The presence of coarse crackles suggests the need to clear secretions first before adjusting ventilator settings.

Choice C reason:

Performing endotracheal suctioning is the appropriate immediate action. Coarse crackles indicate the presence of secretions in the airway, which can impair ventilation and oxygenation. Suctioning helps clear the airway and improve the patient's SaO2 levels.

Choice D reason:

Repositioning the patient can help with ventilation and comfort but is not the priority action when there are indications of airway obstruction. Clearing the airway through suctioning takes precedence in this scenario.

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Correct Answer is C

Explanation

Choice A reason:

Lower levels of arterial carbon dioxide do not directly facilitate brain oxygenation. While maintaining appropriate CO2 levels is important for overall respiratory function, the primary reason for targeting a specific PaCO2 range in traumatic brain injury is related to intracranial pressure control.

Choice B reason:

Although carbon dioxide is indeed a waste product that must be eliminated from the body, this statement does not explain why specific PaCO2 levels are targeted in the context of traumatic brain injury. The primary concern is the impact of CO2 on intracranial pressure.

Choice C reason:

Carbon dioxide is a potent vasodilator, and elevated levels can lead to increased intracranial pressure (ICP). By maintaining PaCO2 within a range of 35-38 mmHg, the healthcare provider aims to prevent hypercapnia and the resulting vasodilation, which can exacerbate intracranial hypertension in patients with traumatic brain injury.

Choice D reason:

Lower levels of arterial carbon dioxide are not specifically essential for gas exchange. The primary concern with PaCO2 management in traumatic brain injury is controlling intracranial pressure, rather than optimizing gas exchange alone.

A. Serum blood glucose of 128 mg/dL B. Blood pressure of 83/51 mmHg C. Hemoglobin level of 13 g/dL D. Core body temperature of 97.8 degrees F

Correct Answer is B

Explanation

Choice A reason:

A serum blood glucose level of 128 mg/dL is slightly elevated but not immediately concerning in the context of organ donation. Blood glucose levels can be managed with insulin if necessary, and this value does not indicate an acute issue requiring immediate intervention.

Choice B reason:

A blood pressure of 83/51 mmHg is critically low and requires immediate action. Low blood pressure can compromise organ perfusion and oxygen delivery, potentially leading to organ damage. In the context of organ donation, maintaining adequate perfusion pressure is essential to ensure the viability of the organs for transplantation.

Choice C reason:

A hemoglobin level of 13 g/dL is within the normal range and does not require immediate intervention. Hemoglobin levels are important for oxygen-carrying capacity but are not the priority concern six hours before organ harvesting if the value is within normal limits.

Choice D reason:

A core body temperature of 97.8 degrees F is slightly below normal but not immediately alarming. Mild hypothermia can be addressed with warming measures, and this temperature does not indicate a critical issue that requires urgent action.

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A patient with Acute Respiratory Distress Syndrome is mechanically ventilated. Coarse crackles are heard over upper airways, the SaO2 has dropped to 85%, and the patient is agitated. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Why does the healthcare provider prescribe a ventilator setting to maintain partial pressure of arterial carbon dioxide (PaCO2) between 35 and 38 mmHg for a patient with traumatic brain injury?

Correct Answer is C

Explanation

The nurse is managing a donor patient six hours prior to the scheduled harvesting of the patient's organs. Which assessment finding requires immediate action by the nurse?

Correct Answer is B

Explanation

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