The nurse is caring for a client with acute respiratory distress syndrome (ARDS) secondary to a chest injury. The client has crackles in the bilateral posterior lung fields, tachycardia, delayed capillary refill, decreased urine output, and the following arterial blood gas (ABG) results: pH 7.56, PaO2 51, PaCo2 58, HCO3 24, SaO2 76%. Which is the healthcare team's priority?

Implement strict urine output monitoring

Administer prescribed furosemide

Place the client in a prone position

Placement of an endotracheal tube

Answer and Explanation

The Correct Answer is D

A. While monitoring urine output is important in ARDS and shock to assess perfusion, it does not address the immediate life-threatening hypoxemia and respiratory failure demonstrated by PaO2 51 mmHg and SaO2 76%.

B. Furosemide may be used to manage pulmonary edema in ARDS, but diuresis is not the first priority when the patient is severely hypoxemic and at risk of respiratory arrest. Giving diuretics before securing the airway could worsen hypoperfusion and oxygenation.

C. Prone positioning can improve oxygenation in ARDS and is an important intervention, but it cannot replace the need for airway management in a patient with severe hypoxemia and hypercapnia.

D. The ABG results indicate severe hypoxemia (PaO2 51, SaO2 76%) and hypercapnia (PaCO2 58) with alkalemia (pH 7.56 likely from compensatory mechanisms or ventilatory pattern changes). These findings signal impending respiratory failure, making endotracheal intubation and mechanical ventilation the priority to maintain oxygenation, ventilation, and prevent further organ dysfunction.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is A

Explanation

A. Septic shock is a major risk factor for ARDSbecause it triggers a systemic inflammatory response, causing increased capillary permeability, pulmonary edema, and alveolar injury. The resulting hypoxemia and lung inflammation can rapidly progress to ARDS.

B. COPD is a chronic lung diseasecharacterized by airflow limitation, but it does not directly trigger the acute inflammatory lung injuryseen in ARDS. Patients with COPD may have baseline hypoxemia, which can complicate ARDS, but it is not a primary risk factor.

C. Asthma is an obstructive airway diseasewith reversible bronchoconstriction. While severe asthma attacks can cause hypoxemia, asthma itself does not directly cause the alveolar-capillary damage characteristic of ARDS.

D. Heart failure can lead to cardiogenic pulmonary edema, which is not classified as ARDS, since ARDS is a non-cardiogenic form of pulmonary edemacaused by inflammation and increased vascular permeability rather than hydrostatic pressure.

A. Monitoring for the presence of bubbling in the suction chamber B. Increasing the amount of suction if drainage decreases C. Observing the amount of fluid in the drainage tubing D. Preparing for removal of chest tube system after 24 hours

Correct Answer is C

Explanation

A. Continuous bubbling in a suction chest tube can indicate an air leak. In a properly functioning wet suction system, intermittent bubbling is normal in the water seal chamber, but bubbling in the suction chamber itself is not always required. Monitoring for air leaks is important, but the presence of suction bubbling is not the primary focus for patient care monitoring.

B. Suction levels are prescribed by the healthcare providerand should not be increased based on decreased drainage. Drainage may decrease naturally as the pneumothorax resolves. Changing suction settings independently can cause lung trauma or excessive negative pressure.

C. Monitoring drainage amount and coloris a primary nursing responsibility. It provides information about ongoing bleeding, air leaks, or resolution of the pneumothorax. Sudden increases or changes in drainage can indicate complicationsthat require prompt intervention.

D. Chest tube removal is not time-dependent; it is based on clinical assessment, radiographic evidence of lung re-expansion, and absence of significant air leaks or drainage. Premature removal could lead to recurrence of the pneumothorax.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following conditions can place a client at risk for acute respiratory distress syndrome (ARDS)?

Correct Answer is A

Explanation

The nurse is caring for a client with a pneumothorax who has a chest tube connected to a closed drainage system with suction. Which of the following actions should the nurse include in the plan of care?

Correct Answer is C

Explanation

The nurse is caring for a client experiencing tachypnea, dyspnea, and confusion. Which of the following orders does the nurse anticipate receiving from the healthcare provider? Select all that apply

The emergency room nurse is caring for a client admitted from the penitentiary. What concepts will the nurse prioritize? Select all that apply

The nurse is assessing a client who sustained a blunt chest injury. Which would indicate to the nurse that the client is exhibiting a flail chest?

Which client will the emergency nurse triage as the priority?

The nurse is triaging a 65-year-old patient who arrived at the triage area with complaints of diaphoresis, dizziness, and left-sided chest pain. What category is appropriate?

The nurse is caring for a client diagnosed with septic shock. Which finding would lead the nurse to suspect the client is developing disseminated intravascular coagulation (DIC)?

A nurse is field-triaging clients after an industrial accident. Which client condition would the nurse triage with a red tag?