The nurse is caring for a client in acute respiratory distress syndrome (ARDS). The chest x-ray displays evidence of pulmonary edema. The nurse assesses the client for which clinical manifestation?

Wheezes on inspiration

Blood pressure 170/90

Tachypnea

Bradycardia

Answer and Explanation

The Correct Answer is C

A. Wheezes on inspiration: Wheezing is typically associated with obstructive pulmonary conditions, such as asthma or chronic obstructive pulmonary disease (COPD), and is caused by narrowing of the airways. In ARDS, the pathophysiology involves inflammation and fluid accumulation in the alveoli, which leads to impaired oxygen exchange but not typically to wheezing. Instead, crackles or rales (a fine, wet sound) are more commonly heard on auscultation in ARDS, particularly as fluid builds up in the alveoli.

B. Blood pressure 170/90: Although ARDS can be associated with hemodynamic instability, elevated blood pressure (170/90 mmHg) is not a typical finding. In fact, ARDS is more commonly associated with low blood pressure or hypotension, particularly if the client is experiencing shock or is on mechanical ventilation. Elevated blood pressure could suggest another issue, such as pain, anxiety, or the use of medications like vasopressors. It is not directly related to the pulmonary edema seen in ARDS.

C. Tachypnea: Tachypnea, or rapid breathing, is a hallmark clinical manifestation of acute respiratory distress syndrome (ARDS). In ARDS, pulmonary edema (fluid accumulation in the lungs) occurs as a result of damage to the alveolar-capillary membrane, leading to impaired gas exchange. The body attempts to compensate for decreased oxygenation by increasing the respiratory rate, leading to tachypnea. This is an early sign of respiratory distress and often precedes hypoxemia and other more severe manifestations. The nurse should closely monitor for tachypnea, as it can indicate worsening respiratory compromise.

D. Bradycardia: Bradycardia, or a slow heart rate, is not typically associated with ARDS. In fact, tachycardia (an elevated heart rate) is more commonly seen in response to hypoxia, respiratory distress, or as a compensatory mechanism for low blood pressure in critical illness. Bradycardia could indicate other issues such as vagal stimulation, medication effects, or electrolyte imbalances but is not characteristic of ARDS itself. 4o mini

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Correct Answer is A

Explanation

A) Endotracheal intubation with mechanical ventilation:
Given the client’s lethargy, slow response to commands, and critical vital signs (e.g., low blood pressure of 88/52, high pulse rate of 132, respiratory rate of 8, and oxygen saturation of 84%), the client is in severe respiratory distress and may be at risk for respiratory failure. The low SpO2 of 84% on a 35% Venturi mask indicates that the client is not adequately oxygenating despite non-invasive oxygen support. In such situations, endotracheal intubation with mechanical ventilation is required to ensure adequate ventilation, oxygenation, and airway protection. This is the most appropriate intervention for a client in respiratory failure who is not responding to less invasive interventions like oxygen therapy or non-invasive ventilation.

B) Use of bi-level positive airway pressure ventilation (BiPAP):
BiPAP is a non-invasive ventilation option that is often used for patients with respiratory failure, particularly those with obstructive or central sleep apnea or those in the early stages of acute respiratory failure (e.g., chronic obstructive pulmonary disease exacerbations). However, given the client’s level of lethargy and deteriorating vital signs, BiPAP may not be sufficient. This client is showing signs of severe respiratory distress and requires more invasive management, such as endotracheal intubation and mechanical ventilation, to maintain an open airway and ensure adequate oxygenation and ventilation.

C) Administration of 100% oxygen by mask:
While oxygen administration is essential to manage respiratory failure, providing 100% oxygen via mask alone is unlikely to resolve the client's underlying issues, especially since the client’s oxygen saturation is critically low (84%) on 35% Venturi mask. Simply increasing the oxygen concentration will not be effective if the client’s respiratory failure is severe and the airway is compromised. More aggressive interventions, such as intubation, are necessary to manage the client’s airway and respiratory function appropriately.

D) Insertion of an oral airway device to maintain the airway:
An oral airway device is typically used for clients who are unconscious or semi-conscious to help keep the airway open. However, in this case, the client is lethargic but not fully unconscious, and the underlying issue is respiratory failure, not just a blocked airway. An oral airway device will not address the client’s inadequate ventilation or oxygenation and will not be sufficient to manage the client’s critical condition. The client requires intubation and mechanical ventilation to ensure adequate airway management and respiratory support.

A. Guidewire-induced dysrhythmia B. Pneumothorax C. Pulmonary infarction D. Venous thrombosis

Correct Answer is B

Explanation

A. Guidewire-induced dysrhythmia: Guidewire-induced dysrhythmia can occur if the guidewire or catheter irritates the heart during insertion, particularly when the catheter is placed in the central venous system. While this can lead to arrhythmias, it is typically more immediate and occurs during the procedure itself. The symptoms of dysrhythmia (e.g., irregular heartbeat) would more likely present right after insertion or during the manipulation of the guidewire. The signs of restlessness, JVD, and tachycardia observed 30 minutes after placement are more suggestive of a pneumothorax than of a guidewire-induced dysrhythmia.

B. Pneumothorax: Pneumothorax is a potential complication of central venous catheter (CVC) placement, particularly when the catheter is inserted into the subclavian vein. The right subclavian vein is located near the apex of the lung, so inadvertent puncture of the lung during catheter placement can lead to air entering the pleural space, causing a pneumothorax. The symptoms of pneumothorax may include restlessness, tachycardia, jugular vein distention (JVD), and respiratory distress. A heart rate of 120 beats per minute is consistent with tachycardia due to hypoxia or distress, and JVD can be a sign of increased intrathoracic pressure or impaired venous return, which occurs with a pneumothorax. These symptoms warrant immediate assessment for pneumothorax, which can be confirmed with a chest x-ray.

C. Pulmonary infarction: Pulmonary infarction occurs when a blockage in the pulmonary arteries prevents blood flow to lung tissue, resulting in tissue death. This can be caused by a pulmonary embolism or other issues, but it is not a typical complication of central venous catheter placement. The symptoms described (restlessness, JVD, and tachycardia) are more consistent with a pneumothorax than a pulmonary infarction, which would likely cause chest pain, hemoptysis, or dyspnea rather than these signs.

D. Venous thrombosis: While venous thrombosis (or clot formation) is a potential complication of central venous catheter placement, it typically manifests as swelling, redness, or pain at the catheter insertion site, rather than with the systemic symptoms of restlessness, tachycardia, and JVD. Venous thrombosis could cause some of the described symptoms in the long term, but it is less likely to be the cause of acute symptoms 30 minutes post-procedure. The immediate concern in this case is more likely to be pneumothorax, which can occur more suddenly and cause these symptoms.Top of FormBottom of Form

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The nurse is caring for a client in acute respiratory distress syndrome (ARDS). The chest x-ray displays evidence of pulmonary edema. The nurse assesses the client for which clinical manifestation?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Correct Answer is B

Explanation

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