The nursing is caring for a client in the Intensive Care Unit on a ventilator. Which intervention(s) should the nurse implement? (SELECT ALL THAT APPLY)

Monitor the client's pulse oximetry every shift

Assess the client's respiratory status at least every 1-2 hours

Ensure that a manual resuscitation bag is at the bedside

Check the ventilator settings every shift

Collaborate frequently with the respiratory therapist

Answer and Explanation

Correct Answer : B,C,D,E

A) Monitor the client's pulse oximetry every shift:
Monitoring pulse oximetry every shift is not sufficient when caring for a client on a ventilator. Pulse oximetry provides valuable information about oxygen saturation, but it should be checked more frequently, especially in a critically ill patient on a ventilator. Continuous monitoring may be required to ensure that oxygenation is maintained at optimal levels. The nurse should assess the pulse oximetry regularly and take immediate action if there is a significant change in the client’s oxygen saturation.

B) Assess the client's respiratory status at least every 1-2 hours:
It is essential to assess the client's respiratory status frequently when they are on a ventilator. Respiratory assessments should be performed at least every 1-2 hours to monitor for complications such as ventilator-associated pneumonia, changes in oxygenation, or the need for adjustments to the ventilator settings. Regular assessment is critical to detect early signs of deterioration and respond promptly.

C) Ensure that a manual resuscitation bag is at the bedside:
Having a manual resuscitation bag (e.g., Ambu bag) at the bedside is a critical intervention for clients on a ventilator. In case of ventilator malfunction, extubation, or respiratory distress, the nurse must have immediate access to a resuscitation bag to manually ventilate the patient. This is a lifesaving piece of equipment that should always be present and ready for use.

D) Check the ventilator settings every shift:
It is essential to check ventilator settings every shift to ensure that the ventilator is functioning correctly and providing the appropriate levels of support for the patient. This includes checking settings such as tidal volume, respiratory rate, pressure, and FiO2 (fraction of inspired oxygen) to ensure they are appropriate for the client's condition. Regular checks can help detect problems such as changes in settings or malfunctioning equipment.

E) Collaborate frequently with the respiratory therapist:
Frequent collaboration with the respiratory therapist is crucial when managing a client on a ventilator. Respiratory therapists are experts in ventilator management and can provide valuable insight into adjusting settings, interpreting ABGs, troubleshooting equipment issues, and optimizing respiratory care. Collaborative care helps ensure that the client is receiving the most appropriate interventions and adjustments for their respiratory status.

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Correct Answer is C

Explanation

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

Correct Answer is ["56"]

Explanation

Calculate the infusion rate in mL/min.

The total volume to be infused is 500 mL.

The infusion time is 90 minutes.

The infusion rate = 500 mL / 90 minutes = 5.5556 mL/min.

Calculate the drip rate in gtt/min.

The drop factor is 10 gtt/mL.

We need to deliver 5.5556 mL/min.

To find the drip rate, we can set up a proportion:

10 gtt / 1 mL = x gtt / 5.5556 mL

Cross-multiplying:

x = 10 gtt/mL x 5.5556 mL = 55.5556 gtt

Round the answer to the nearest whole number.

56 gtt/min.

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The nursing is caring for a client in the Intensive Care Unit on a ventilator. Which intervention(s) should the nurse implement? (SELECT ALL THAT APPLY)

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Naxlex Comprehensive Predictor Exams

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?

Correct Answer is C

Explanation

A patient is prescribed 500 ml of Normal Saline to be infused over 90 minutes. The drop factor on the tubing is 10 gtt/mL. At what rate should the nurse regulate the IV (gtt/min)? (Round to the nearest whole number)

Correct Answer is ["56"]

Explanation

The nurse caring for a critically ill client would suspect the development of acute respiratory distress syndrome (ARDS) in which of the following situations? The client with:

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