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

The patient is experiencing bradypnea.

The patient is tired and confused.

The patient's PaO2 remains at 45 mmHg.

The patient's blood pressure is 180/96.

Answer and Explanation

The Correct Answer is C

Rationale:

A. The patient is experiencing bradypnea is incorrect because ARDS is typically associated with tachypnea, not bradypnea. Patients initially respond to hypoxemia by increasing their respiratory rate to improve oxygenation.

B. The patient is tired and confused is incorrect because while altered mental status can occur due to hypoxemia, it is a secondary symptom, not the hallmark diagnostic feature of ARDS.

C. The patient's PaO2 remains at 45 mmHg is correct. A hallmark of ARDS is severe hypoxemia that persists despite 100% oxygen delivery. In ARDS, inflammation and alveolar damage lead to non-cardiogenic pulmonary edema, reducing gas exchange. This refractory hypoxemia is a key diagnostic criterion for ARDS and distinguishes it from other causes of respiratory distress.

D. The patient's blood pressure is 180/96 is incorrect because ARDS is primarily a pulmonary disorder, not a hypertensive emergency. Blood pressure changes may occur secondary to stress or sepsis, but they are not hallmark signs of ARDS.

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Correct Answer is ["B","E"]

Explanation

Rationale:

A. Anxiety and fear usually increase respiratory rate and depth (hyperventilation). Hyperventilation blows off CO2, which can lead to respiratory alkalosis, not acidosis. Therefore, anxiety is not a predisposing factor for respiratory acidosis.

B. CNS depression from conditions such as stroke, brain injury, sedation, or neurologic disease can suppress the respiratory drive, leading to hypoventilation. Hypoventilation results in CO2 retention, which increases PaCO2 and lowers pH, producing respiratory acidosis.

C. DKA causes metabolic acidosis due to the accumulation of ketone bodies. The patient often develops Kussmaul respirations (deep, rapid breathing) to blow off CO2 as a compensatory mechanism, which is opposite of respiratory acidosis.

D. NG suctioning removes gastric acid, which can lead to loss of hydrogen ions, causing metabolic alkalosis, not respiratory acidosis. It does not directly affect CO2 elimination or the respiratory system.

E. Sedatives such as benzodiazepines, opioids, or barbiturates depress the CNS, including the respiratory centers in the medulla. This leads to hypoventilation, decreased alveolar ventilation, and CO2 retention, resulting in respiratory acidosis.

A. An older adult with an pulse ox of 96% on room air B. An adult client with a pulse ox of 94% on room air C. A young adult with an arterial oxygen level of 82 on 2 L/min D. A young adult with an arterial oxygen level of 94 on room air

Correct Answer is C

Explanation

Rationale:

A. This oxygen saturation is within normal limits (95–100%). While age may slightly reduce baseline oxygenation, 96% is acceptable, and the patient is stable. There is no immediate threat to respiratory function, so this patient does not require urgent attention.

B. A saturation of 94% is slightly below normal but generally considered mild hypoxemia. The patient is likely compensating and may not require immediate intervention. Continuous monitoring is appropriate, but urgent evaluation is not required unless symptoms develop.

C. This patient is hypoxemic despite supplemental oxygen, which is more serious than a patient with normal or slightly low oxygen on room air. Normally, PaO2 should rise above 80 mm Hg with supplemental oxygen. Failure to achieve adequate oxygenation on 2 L/min indicates compromised gas exchange, possibly from pneumonia, ARDS, pulmonary embolism, or worsening respiratory failure. This patient is at highest risk for rapid deterioration, making them the priority. Immediate assessment, titration of oxygen, or escalation of care may be required.

D. PaO2 of 94 mm Hg is within normal limits (80–100 mm Hg). This patient is stable and does not require urgent intervention.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Select all of the factors that may predispose the patient to respiratory acidosis. Select all that apply.

Correct Answer is ["B","E"]

Explanation

The nurse is caring for several clients on a respiratory unit. Which client will the nurse see first?

Correct Answer is C

Explanation

A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration?

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A patient's status worsens and he needs mechanical ventilation. The pulmonologist wants him to receive 10 breaths/min minute from the ventilator but wants to encourage him to breathe spontaneously in between the mechanical breaths at his own tidal volume. This mode of ventilation is called:

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