Success( ACUTE RESP DISTRESS SYNDROME)
ARDS questions Exam 3 Answered
The unlicensed assistive personnel (UAP) is bathing the client diagnosed with acute respiratory distress syndrome (ARDS). The bed is in a high position with the opposite side rail in the low position. Which action should the ...
Success( ACUTE RESP DISTRESS SYNDROME)
ARDS questions Exam 3 Answered
The unlicensed assistive personnel (UAP) is bathing the client diagnosed with acute respiratory
distress syndrome (ARDS). The bed is in a high position with the opposite side rail in the low position.
Which action should the nurse implement?
1. Demonstrate the correct technique for giving a bed bath.
2. Encourage the UAP to put the bed in the lowest position.
3. Instruct the UAP to get another person to help with the bath.
4. Provide praise for performing the bath safely for the client and the UAP.
ANS: 1. The opposite side rail should be elevated so the client will not fall out of the bed. Safety is
priority, the nurse should demonstrate the proper way to bathe a client in the bed.
2. The bed should be at a comfortable height for the UAP to bathe the client, not in the lowest position.
3. The UAP can bathe a client without assistance if the client's safety can be ensured.
4. The UAP is not ensuring the client's safety because the opposite side rail is not elevated to prevent
the client from falling out of the bed.
The client diagnosed with ARDS is transferred to the intensive care department and placed on a
ventilator. Which intervention should the nurse implement first?
1. Confirm that the ventilator settings are correct.
2. Verify that the ventilator alarms are functioning properly.
3. Assess the respiratory status and pulse oximeter reading.
4. Monitor the client's arterial blood gas results.
ANS: 3. Assessment is the first part of the nursing process and is the first intervention the nurse should
implement when caring for a client on a ventilator.
1. Maintaining ventilator settings and checking to ensure they are specifically set as prescribed is
appropriate, but it is not the first intervention.
2. Making sure alarms are functioning properly is appropriate, but checking a machine is not priority.
4. Monitoring laboratory results is an appropriate intervention for the client on a ventilator, but
monitoring laboratory data is not the priority intervention.
The nurse suspects the client may be developing ARDS. Which assessment data confirm the diagnosis
of ARDS?
1. Low arterial oxygen when administering high concentration of oxygen.
2. The client has dyspnea and tachycardia and is feeling anxious.
, 3. Bilateral breath sounds clear and pulse oximeter reading is 95%.
4. The client has jugular vein distention and frothy sputum.
ANS: 1. The classic sign of ARDS is decreased arterial oxygen level (PaO2) while administering high levels
of oxygen; the oxygen is unable to cross the alveolar membrane.
2. These are early signs of ARDS, but they could also indicate pneumonia, atelectasis, and other
pulmonary complications, so they do not confirm the diagnosis of ARDS.
3. Clear breath sounds and the oxygen saturation indicate the client is not experiencing any respiratory
difficulty or compromise.
4. These are signs of congestive heart failure; ARDS is noncardiogenic (without signs of cardiac
involvement) pulmonary edema.
The client who smokes two (2) packs of cigarettes a day develops ARDS after a near-drowning. The
client asks the nurse, "What is happening to me? Why did I get this?" Which statement by the nurse is
most appropriate?
1. "Most people who almost drown end up developing ARDS."
2. "Platelets and fluid enter the alveoli due to permeability instability."
3. "Your lungs are filling up with fluid, causing breathing problems."
4. "Smoking has caused your lungs to become weakened, so you got ARDS."
ANS: 3. This is a basic layperson's terms explanation of ARDS and explains why the client is having
trouble breathing.
1. This is an incorrect statement. ARDS has multiple etiologies, such as hemorrhagic shock, septic shock,
drug overdose, burns, and near-drowning. Many people with near-drowning do not develop ARDS.
2. The layperson may not know what the term alveoli means, and the near-drowning is the initial insult
that caused the ARDS.
4. Smoking does not increase the risk of developing ARDS. The etiology is unknown, but an initial insult
occurs 24 to 48 hours before the development of ARDS.
Which assessment data indicate to the nurse the client diagnosed with ARDS has experienced a
complication secondary to the ventilator?
1. The client's urine output is 100 mL in four (4) hours.
2. The pulse oximeter reading is greater than 95%.
3. The client has asymmetrical chest expansion.
4. The telemetry reading shows sinus tachycardia.
ANS: 3. Asymmetrical chest expansion indicates the client has had a pneumothorax, which is a
complication of mechanical ventilation.
1. A urine output of 30 mL/hr indicates the kidneys are functioning properly.
2. This indicates the client is being adequately oxygenated.
4. An increased heart rate does not indicate a complication; this could result from numerous reasons,
not specifically because of the ventilator.
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