You are providing care to a patient who is being treated for aspiration pneumonia. The client is on a 100% non-rebreather mask. Which finding below is a HALLMARK sign and symptom that the client is developing acute respiratory distress syndrome (ARDS)?

The client is experiencing bradypnea.

The client's PaCO2 is 50 mmHg.

The client's blood pressure is 170/96.

The client's PaO2 remains at 40 mmHg

Answer and Explanation

The Correct Answer is D

A. Bradypnea is not a hallmark sign of ARDS; ARDS typically involves tachypnea or rapid breathing.
B. An elevated PaCO2 indicates hypercapnia but is not specific to ARDS.
C. Elevated blood pressure is not a specific indicator of ARDS.
D. A persistently low PaO2 despite receiving high-flow oxygen (such as from a non-rebreather mask) is a hallmark sign of ARDS, indicating severe hypoxemia and impaired gas exchange.

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Correct Answer is D

Explanation

A. Applying restraints should be a last resort and only if less restrictive measures have failed. It is also essential to follow legal and ethical guidelines regarding the use of restraints.

B. Calling the family to stay with the client may provide temporary comfort but does not directly address safety concerns or the underlying cause of restlessness and confusion.

C. Sedating the client might not be appropriate without first assessing the cause of the restlessness and confusion. Medications should be used cautiously and based on a thorough evaluation.

D. Moving the client closer to the nurses' station allows for more frequent monitoring and quick intervention if needed, addressing the immediate safety concern of restlessness and confusion. This measure helps ensure the client’s safety while further assessment and intervention are being planned.

A. Heart rate B. BP C. Weight D. Urine output

Correct Answer is A

Explanation

A. A decrease in heart rate can indicate adequate fluid resuscitation as it suggests improved circulatory status and reduced compensatory tachycardia, which is a response to hypovolemia.
B. An increase, rather than a decrease, in blood pressure would typically indicate improved fluid status and perfusion following adequate fluid resuscitation.
C. Weight changes are not an immediate indicator of fluid resuscitation adequacy. Weight reflects overall fluid balance over a longer period.
D. An increase, not a decrease, in urine output is expected with adequate fluid resuscitation, as improved renal perfusion results in better urine production.

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You are providing care to a patient who is being treated for aspiration pneumonia. The client is on a 100% non-rebreather mask. Which finding below is a HALLMARK sign and symptom that the client is developing acute respiratory distress syndrome (ARDS)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Explanation

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