An adult patient is admitted to the ICU with Acute Respiratory Distress Syndrome (ARDS). The patient has been intubated and is mechanically ventilated. The patient is becoming increasingly agitated, and the high-pressure alarm is frequently being triggered. Which of the following interventions would the nurse do first? 1.25 Points
Assess the client for a physiologic reason for his agitation
Administer a bolus dose of IV antianxiolytic
Obtain a stat ABG
Apply soft wrist restraints
The Correct Answer is A
A. Assess the client for a physiologic reason for his agitation is correct because agitation in an intubated, mechanically ventilated patient can indicate hypoxia, hypercapnia, pain, airway obstruction, or other acute physiologic problems. High-pressure alarms are often triggered by secretions, bronchospasm, coughing, or patient-ventilator dyssynchrony, and these causes must be identified and corrected immediately before implementing sedation or restraints. Assessment is always the first step in the nursing process.
B. Administer a bolus dose of IV antianxiolytic is incorrect because giving medication without first determining the underlying cause could mask important signs of deterioration, such as hypoxia or ventilator obstruction. Sedation is secondary to addressing the primary physiologic problem.
C. Obtain a stat ABG is incorrect as the first action because while ABGs provide important data about oxygenation and ventilation, the immediate cause of agitation and high ventilator pressures needs to be addressed first, such as suctioning secretions or checking tubing. ABGs can follow after rapid assessment and interventions.
D. Apply soft wrist restraints is incorrect because restraints do not treat the underlying cause of agitation and may worsen anxiety or increase oxygen demand. Restraints are considered only if the patient poses a risk of self-harm or removing the endotracheal tube after addressing physiologic needs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Elevated serum creatinine indicates impaired renal function, which is a sign of organ dysfunction. In cardiogenic shock, decreased cardiac output reduces perfusion to vital organs, and rising creatinine is an early indicator of kidney involvementin MODS. This finding reflects multi-organ compromiserather than isolated symptoms.
B. Chest pressure reflects ongoing myocardial ischemia, which is the underlying cause of cardiogenic shock, but it does not indicate that other organs are failing.
C. Wheezing may indicate pulmonary congestion or fluid overload, but it is not specific for MODS. It reflects one organ systemrather than multi-organ dysfunction.
D. Cool extremities and weak pulses indicate poor perfusion and peripheral vasoconstriction, common in shock. While concerning, these are signs of inadequate circulationrather than definitive evidence of multiple organ failure.
Correct Answer is D
Explanation
A. Although it may seem intuitive to cool the bite site, ice is not recommendedin snakebite management. Cooling can damage local tissueand does not slow the systemic spread of venom. Applying ice can actually worsen tissue injury and delay healing.
B. Techniques such as suction or cutting the bite siteare outdated and ineffective. Studies show that attempting to extract venom orally does not remove enough venom to impact outcomesand increases the risk of infection or further tissue damage.
C. Tourniquets are contraindicatedbecause they can restrict blood flow, leading to tissue ischemia, necrosis, and permanent damage. Additionally, sudden release of a tourniquet may cause a surge of venom into the circulation, worsening systemic toxicity.
D. Immobilization helps slow lymphatic spread of venom, reducing systemic absorption. Keeping the limb at or slightly below heart levelprevents unnecessary venom circulation while avoiding excessive swelling that would occur if the limb were elevated above the heart. The patient should remain calm and limit movementto reduce venom distribution. Emergency medical services should be contacted immediately for assessment, antivenom administration if indicated, and monitoring of vital signs and systemic effects.
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