The nurse interprets which finding as an early sign of acute respiratory distress syndrome (ARDS) in a client at risk?

Hypoxia not responsive to oxygen therapy

Elevated lactate levels

Metabolic alkalosis

Severe, unexplained electrolyte imbalance

Answer and Explanation

The Correct Answer is A

Choice A reason:

Hypoxia not responsive to oxygen therapy is a hallmark early sign of ARDS. ARDS is characterized by acute onset of hypoxemia that does not improve with supplemental oxygen. This refractory hypoxemia is due to severe inflammation and increased permeability of the alveolar-capillary barrier, leading to pulmonary edema and impaired gas exchange.

Choice B reason:

Elevated lactate levels can indicate tissue hypoxia and metabolic stress, which are concerning findings in critically ill patients. However, elevated lactate is not specific to ARDS and can be seen in various conditions, including sepsis and shock. It is not the primary early indicator of ARDS.

Choice C reason:

Metabolic alkalosis is not typically associated with ARDS. ARDS usually involves respiratory failure, which may lead to respiratory acidosis. Metabolic alkalosis can occur in other conditions, such as excessive loss of gastric acid or diuretic use, but it is not an early sign of ARDS.

Choice D reason:

Severe, unexplained electrolyte imbalance can occur in critically ill patients but is not specific to ARDS. Electrolyte imbalances can result from various factors, including fluid shifts, renal dysfunction, and medication effects. These imbalances do not serve as an early diagnostic indicator of ARDS.

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Correct Answer is C

Explanation

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.

A. Soak the pin sites with alcohol pads B. Remove the vest when bathing the patient C. Assess the chest and back for skin breakdown D. Assess pin sites frequently for signs of infection E. Tape a halo wrench to the vest for emergencies

Correct Answer is ["C","D","E"]

Explanation

Choice A reason:

Soaking the pin sites with alcohol pads is not recommended as it can dry out the skin and increase the risk of infection. Pin site care typically involves using saline or other recommended solutions to clean the area gently.

Choice B reason:

Removing the vest when bathing the patient is not recommended. The vest provides stability and support for the spinal fracture, and removing it can compromise the patient's safety. Alternative methods should be used to maintain hygiene without removing the vest.

Choice C reason:

Assessing the chest and back for skin breakdown is crucial in patients with a halo device to prevent pressure ulcers and other skin issues. Regular assessment helps identify any potential problems early.

Choice D reason:

Assessing pin sites frequently for signs of infection is essential to prevent complications. Infection at the pin sites can lead to serious issues, and frequent monitoring ensures any signs of infection are caught and treated promptly.

Choice E reason:

Taping a halo wrench to the vest is important for emergencies. The wrench is necessary to quickly remove the halo device if needed in an emergency situation, such as if the patient requires resuscitation.

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The nurse interprets which finding as an early sign of acute respiratory distress syndrome (ARDS) in a client at risk?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

The nurse is preparing to care for a patient with a spinal fracture who has a halo device in place. The nurse plans to implement the following orders:

Correct Answer is ["C","D","E"]

Explanation

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