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 A

Explanation

Choice A reason:

Palpating the bladder for distention is the first action the nurse should take. The patient's symptoms suggest autonomic dysreflexia, a condition that can be triggered by bladder distention. Relieving the distention can help resolve the hypertensive crisis.

Choice B reason:

Initiating oxygen via a nasal cannula may be necessary if the patient is experiencing respiratory distress, but it is not the primary intervention for autonomic dysreflexia. The focus should be on identifying and resolving the triggering cause.

Choice C reason:

Placing the patient in a supine position is contraindicated in autonomic dysreflexia as it can worsen the condition by further increasing blood pressure. The patient should be positioned upright if tolerated.

Choice D reason:

Administering a prescribed beta-blocker may help lower blood pressure, but it is not the first action. The underlying cause of autonomic dysreflexia must be addressed to prevent recurrence.

A. The spouse assists the client into a wheelchair and coaches deep coughing. B. The spouse assists the client into high-Fowler position and encourages taking a number of deep breaths. C. The spouse places hands on the client's lateral chest and pushes inward on exhalation. D. The spouse places hands below the client's diaphragm and pushes upward with exhalation.

Correct Answer is D

Explanation

Choice A reason:

While assisting the client into a wheelchair and coaching deep coughing can be beneficial, it does not specifically describe the technique for performing assistive coughing, which is crucial for a quadriplegic patient who cannot generate effective coughs on their own.

Choice B reason:

Placing the client in a high-Fowler position and encouraging deep breaths can be helpful in enhancing lung expansion and breathing, but it does not address the specific method of assistive coughing, which requires manual assistance to be effective.

Choice C reason:

Placing hands on the lateral chest and pushing inward on exhalation is not the correct technique for assistive coughing. This method may not generate sufficient force to help with airway clearance in a quadriplegic patient.

Choice D reason:

Placing hands below the client's diaphragm and pushing upward with exhalation is the correct technique for assistive coughing, also known as quad coughing. This method helps to increase the force of the cough, allowing for better clearance of secretions from the airway, which is essential for patients with quadriplegia.

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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

A nurse assesses a patient with a spinal cord injury at level T5. The patient's blood pressure is 184/95 mm Hg, and the patient presents with a flushed face and blurred vision. What action would the nurse take first in response to this complication?

Correct Answer is A

Explanation

Which observation indicates to the nurse that a patient with quadriplegia spouse understands performance of assistive coughing (quad cough)?

Correct Answer is D

Explanation

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