ARDS NCLEX Style Questions

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49 terms Forever_Aela5102 Preview ARDS nclex questions 33 terms almachengray Preview ATI com 198 term h_tr The client diagnosed with ARDS is transferred to the intensive care department and placed on a ventilator.Which intervention should the nurse implement first?

• Confirm that they ventilator settings are correct
• Verify that the ventilator alarms are functioning

properly

• Assess the respiratory status and pulse oximeter

reading.

• Monitor the client's arterial blood gas results
• 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.Never check the machine first.The nurse suspects the client may be developing ARDS.Which assessment data confirm the diagnosis of ARDS?

• Low arterial oxygen when administering high

concentration of oxygen

• The client has dyspnea and tachycardia and feels

anxious

• Bilateral breath sounds clear and pulse oximeter

reading is 95%

• The client has JVD and frothy sputum
• The classic signs of ARDS is decreased arterial oxygen level (PaO2) while

administering high levels of oxygen; the oxygen is unable to cross the alveolar membrane.

The client who smokes two 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?

• Most people who almost drown end up developing

ARDS

• Platelets and fluid enter the alveoli due to permeability

instability.

• Your lungs are filling up with fluid, causing breathing

problems

• Smoking has caused your lungs to become weakened,

so you got ARDS

• This is the basic terms explanation of ARDS and explains why the client is having

trouble breathing.Which assessment data indicate to the nurse the client diagnosed with ARDS has experienced a complication secondary to the ventilator?

• The client's urine output is 100 mL in four hours
• The pulse oximeter reading is greater than 95%
• The client has asymetrical chest expansion
• THe telemetry reading shows sinus tachycardia
• Asymetrical chest expansion indicates the client has a pneuothorax, which is a

complication of mechanical ventilation.The health-care provider ordered STAT arterial blood gases for the client diagnosed with ARDS. The ABG

results are: pH 7.38, PaO2 92, PaCO2 38, HCO3 24. Which

action should the nurse implement?

• Continue to monitor the client without taking any action
• Encourage the client to take deep breaths and cough
• Administer one ampule of sodium bicarbonate IVP
• Notify the respiratory therapist of the results
• The ABGs are within normal limits, and therefore the nurse should not take any

action except to continue to monitor the client The client with ARDS is on a mechanical ventilator. Which intervention should be included in the nursing care plan addressing the endotracheal tube care?

• Do not move or touch the ET tube
• Obtain a chest x-ray daily
• Determine if the ET cuff is deflated
• Ensure that the ET tube is secured
• The ET tube should be secure to ensure that it does not enter the right main

bronchus. The ET tube should be one inch above the bifucation of the bronchi.Which medication should the nurse anticipate the health- care provider ordering for the client diagnosed with ARDS?

• An aminoglycoside antibiotic
• A synthetic surfactant
• A potassium cation
• A nonsteroidal anti-inflammatory drug
• Surfactant therapy may be prescribed to reduce the surface tension in the

aveoli. The surfactant helps maintain open alveoli, decreases the work of breathing, improves compliance, and helps prevent atelectasis.The client diagnosed with ARDS is in respiratory distress and the ventilator is malfunctioning. Which intervention should the nurse implement first?

• Notify the respiratory therapist immediately
• Ventilate with a manual resuscitation bag
• Request STAT ABGs
• Auscultate the client's lung sounds
• If the ventilator system malfunctions, the nurse must ventilate the client with a

manual resuscitation bag until the problem is resolved.

The nurse is caring for a client diagnosed with ARDS.Which interventions should the nurse implement? Select All that Apply

• Assess the client's level of consciousness
• Monitor urine output every shift
• Turn the client every 2 hours
• Maintain intravenous fluids as ordered
• Place the client in the Fowler's position
• Altered LOC is the earliest sign of hypoxemia
• The client is at risk for complications of immobility, therefore, the nurse should

turn the client at least every 2 hours to prevent pressure ulcers

• The client is at risk for fluid volume overload, so the nurse should monitor and

maintain fluid intake

• Fowler's position facilitates lung expansion and reduces the workload of

breathing Which instruction is priority for the nurse to discuss with the client diagnosed with ARDS who is being discharged from the hospital?

• Avoid smoking and exposure to smoke
• Do not receive flu or pneumonia vaccines
• Avoid any type of alcohol intake
• It will take about one month to recuperate
• Not smoking is vital to prevent further lung damage.

The client diagnosed with ARDS is on a ventilator and the high alarm indicates an increase in the peak airway pressure. Which intervention should the nurse implement first?

• Check the tubing for any kinks
• Suction the airway for secretion
• Assess the lip line of the ET tube
• Sedate the client with a muscle relaxant
• When peak airway pressure is increased, the nurse should implement the

intervention least invasive for the client. This alarm goes off with a plugged airway, "bucking" in the ventilator, decreasing lung compliance, kinked tubing or pneumothorax