ARDS nclex questions

ARDS nclex questions ScienceMedicineEmergency Medicine almachengray Save Which S&S distinguish hypoxemia from hypercapnic respiratory failure? SATA

• Cyanosis
• Tachypnea
• Morning headache
• Paradoxical breathing
• Use of pursed lip breathing

A, B, D

A: Cynosis is a late sign of hypoxemia

B: Tachypnea is a sign of hypoxemia

D: Paradoxical breathing is a late sign of hypoxmeia

C & E are S&S of Hypercapnia

A nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing ARDS? (SATA)

• A client who experienced a near drowning
• A client following coronary artery bypass graft surgery
• A client who has a hemoglobin of 15.1 mg/dL
• A client who has dysphagia
• A client who experienced acute drug toxicity

A: CORRECT - near drowning incident is at risk for developing ARDS due to trauma to lungs and cerebral edema.

B: CORRECT - at risk for developing ARDS due to trauma to chest

C: NO - hemoglobin of 15.1 is within expected range. Client with low hemoglobin as at risk for ARDS

D: CORRECT - difficulty swallowing and risk for aspiration

E: CORRECT - damage to central nervous system

An important consideration in selecting an 02 delivery device for the patient with acute hypoxemic respiratory failure is to

• Always start with noninvasive positive pressure ventilation
• Apply a low flow device, such as a nasal cannula or face mask
• Be able to correct the PaO2 to a normal level as quickly as possible
• Base the selection on the patients condition and amount of FIO2 needed

D The most common early manifestations of ARDS that the nurse may see are

• Dyspnea and tachypnea
• Cyanosis and apprehension
• Respiratory distress and frothy sputum
• Bradycardia and increased work of breathing

A

Interventions used in managing the patient with ARDS includes SATA

• IV injection of surfactant
• Aggressive IV fluid resuscitation
• Giving adequate analgesia and sedation
• Elevating the HOB 30-45 degrees when supine
• Monitoring hemodynamic parameters and daily weights

C, D, E

• keep pt dry
• IV injection - could cause bleeding

WHich intervention is most likely to prevent or limit volutrauma in the pt with ARDS who is mechanically ventilated?

• Increasing PEEP
• Increasing the inspiratory flow rate
• Use of low tidal volume ventilation
• Suctioning the patient via endotracheal tube hourly

C

• pt with ARDS are ventilated with a low VT of 4-8 ml/Kg
• low VT ventilation has reduced mortality and risk for volutrauma

The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding?

• Slow, deep respirations
• Rapid, deep respirations
• Paradoxical respirations
• Pain, especially on inspiration

D Typical signs and symptoms include pain and tenderness that is exacerbated by inspiration, shallow respirations,

A pt is in acute respiratory distress syndrome (ARDS) from sepsis. Which measure would be implemented to maintain cardiac output?

• Administer IV crystalloid fluids.
• Place the patient on a strict fluid restriction.
• Position the patient in Trendelenburg position.
• Perform chest physiotherapy and assist with staged coughing.

A Low cardiac output may necessitate crystalloid fluids in addition to lowering positive end- expiratory pressure (PEEP) or giving inotropes. The Trendelenburg position is not recommended to treat hypotension. Chest physiotherapy is unlikely to relieve decreased cardiac output. Fluid restriction would be an inappropriate intervention.A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest?

• Cyanosis
• Hypotension
• Paradoxical chest movement ebt
• Dyspnea, especially on expiration

C Flail chest results from multiple rib fractures. This results in a 'floating' section of ribs. This section is unattached to rest of bony rib cage, and results in paradoxical chest movement.Force of inspiration pulls fractured segment inwards, while rest of body expands.