Which of the following interventions would be most likely to prevent the development of acute respiratory distress syndrome (ARDS)?

Teaching cigarette smoking cessation.

Maintaining adequate serum potassium levels.

Monitoring clients for signs of hypercapnia.

Replacing fluids adequately during hypovolemic states.

Answer and Explanation

The Correct Answer is D

A. Smoking cessation improves long-term respiratory health and decreases the risk of chronic lung diseases such as COPD and lung cancer. However, ARDS is an acute inflammatory lung injury, typically triggered by severe illness, trauma, sepsis, or massive transfusions. Smoking status does not acutely prevent ARDS from developing in critically ill patients.

B. While maintaining electrolyte balance is essential for cellular and cardiac function, potassium levels do not have a direct preventive effect on ARDS. Electrolyte monitoring supports general critical care but does not influence the pathophysiology of acute lung injury.

C. Monitoring for hypercapnia is a reactive measure to detect respiratory compromise, but it does not prevent ARDS. It may help in early recognition of respiratory failure once it begins, but it cannot stop the initial inflammatory cascade or alveolar injury that causes ARDS.

D. ARDS often develops secondary to shock or hypoperfusion, where decreased circulating volume leads to systemic inflammation, increased capillary permeability, and pulmonary edema. Timely fluid resuscitation maintains adequate tissue perfusion, preserves oxygen delivery, and reduces the risk of alveolar damage and progression to ARDS. Proper fluid management also helps prevent organ hypoxia and multi-organ dysfunction, which are common contributors to ARDS development.

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Correct Answer is D

Explanation

A. Warm, flushed skin is more characteristic of the initial or compensatory phases of shock, particularly in distributive or septic shock. In the refractory phase, skin is more likely cool, mottled, or cyanotic, so this is not an immediate red-flag requiring intervention.

B. Low urine output (oliguria) indicates renal hypoperfusion, which is concerning. However, in the context of the refractory phase, this finding is expected due to multi-organ dysfunction. While monitoring and support are needed, bleeding from IV sites requires more urgent action.

C. Tachypnea reflects compensatory attempts to correct hypoxia and acidosis. Although worsening respiratory status is concerning, it is not as immediately life-threateningas active bleeding in a client with coagulation compromise.

D.In the refractory phase of shock, clients may develop disseminated intravascular coagulation (DIC), leading to spontaneous bleeding. Bleeding from IV sites is an acute, emergent complicationthat requires immediate intervention to prevent exsanguination, further hypovolemia, and worsening multi-organ failure. This finding is a sign of severe coagulopathyand signals that the patient is in critical condition requiring rapid response.

A. Assess breath sounds and respiratory efforts B. Establish vascular access with a large-bore catheter C. Remove clothing to perform a complete physical assessment D. Evaluate level of consciousness (LOC) using the Glasgow Coma Sale (GCS)

Correct Answer is A

Explanation

A. In an unconscious patient, airway and breathing take priorityaccording to the ABC (Airway, Breathing, Circulation) approachin emergency care. Even if the patient is breathing spontaneously, the nurse must assess for adequate oxygenation, airway patency, and signs of respiratory compromisebefore addressing other interventions. Immediate identification of airway obstruction or inadequate breathing can be life-saving.

B. Incorrect as the first action. While IV access is important for fluid resuscitation or medication administration, it does not take priority over ensuring airway and effective breathing, which are immediately life-sustaining.

C. Incorrect as the first action. A full physical assessment is important for identifying injuries, but airway and breathing must be addressed first. Removing clothing can occur after the patient is stabilized.

D. Incorrect as the first action. Assessing LOC is important to monitor neurological status, but it does not take priority over ensuring the patient can maintain adequate ventilation and oxygenation. LOC assessment can be done simultaneously or immediately after securing airway and breathing.

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Which of the following interventions would be most likely to prevent the development of acute respiratory distress syndrome (ARDS)?

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Naxlex Comprehensive Predictor Exams

Which assessment finding in a client in the refractory phase of shock requires immediate nursing intervention?

Correct Answer is D

Explanation

What is the nurse's priority action for the unconscious patient who is breathing who has been brought to the ED?

Correct Answer is A

Explanation

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