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 C

Explanation

A. Pain relief is important, but the immediate priority post-surgery is to ensure the client’s airway is not compromised.
B. Promoting oral hygiene is necessary to prevent infection, but it is not the immediate priority.
C. Preventing aspiration is the priority because the client’s jaw is wired shut, increasing the risk of aspiration which can lead to serious respiratory complications.
D. Ensuring adequate nutrition is important for recovery, but it comes after ensuring the client’s airway and breathing are safe and stable.

A. Confusion B. Increased urinary output C. Increased intracranial pressure D. Weakness

Correct Answer is D

Explanation

A. Confusion is not a typical manifestation of myasthenia gravis but could be related to other issues or conditions.
B. Increased urinary output is not directly associated with myasthenia gravis and is not a primary symptom to monitor.
C. Increased intracranial pressure is not characteristic of myasthenia gravis and is unrelated to the condition.
D. Weakness is a hallmark symptom of myasthenia gravis, resulting from impaired communication between nerves and muscles. It is crucial to monitor and assess for changes in muscle strength and fatigue.

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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

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