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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Administering Heparin to a patient who is already taking Warfarin and experiencing rectal bleeding is not appropriate. Heparin is an anticoagulant, similar to Warfarin, and would not help in reversing the anticoagulant effects of Warfarin. Instead, it could potentially exacerbate the bleeding.
Choice B reason:
Vitamin K is the correct answer because it acts as an antidote to Warfarin. Warfarin works by inhibiting the synthesis of Vitamin K-dependent clotting factors, so administering Vitamin K helps to reverse the effects of Warfarin and promote blood clotting, which is necessary to control the rectal bleeding in this patient.
Choice C reason:
Iron is not the appropriate treatment for rectal bleeding due to Warfarin. While iron supplements can help with anemia (which might result from chronic blood loss), they do not address the immediate need to reverse the anticoagulant effects of Warfarin and stop the active bleeding.
Choice D reason:
Protamine is used to reverse the effects of Heparin, not Warfarin. Therefore, administering Protamine would not be effective in addressing the Warfarin-induced rectal bleeding in this patient.
Correct Answer is B
Explanation
Choice A reason:
Young adults ages 12-20 are at risk for spinal cord injuries due to sports and recreational activities. However, the highest risk group for spinal cord injuries, particularly from activities such as motor vehicle accidents and risky behaviors, is young men ages 16-30.
Choice B reason:
Young men ages 16-30 are the highest risk group for spinal cord injuries. This population is more likely to engage in high-risk activities such as driving, contact sports, and recreational activities that can lead to spinal cord injuries. Therefore, they would benefit most from targeted prevention education.
Choice C reason:
Children ages 2-15 are at risk for spinal cord injuries, particularly from falls and accidents. However, their risk is lower compared to the young adult male population. Education for this group is important but not as critical as for young men.
Choice D reason:
Elderly people ages 60 and up are at risk for spinal cord injuries, primarily from falls. While prevention education is important for this group, they are not the highest risk population compared to young men ages 16-30.
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