A nurse is caring for a client.

Exhibits

Which of the following actions should the nurse take? (Select all that apply.)

A. Prepare to assist with intubation of the client: This action should be prioritized for a client diagnosed with acute respiratory distress syndrome (ARDS). ARDS can lead to significant respiratory distress and hypoxemia, requiring advanced airway management. Assisting with intubation ensures that the client receives adequate ventilation and oxygenation, which is critical in managing ARDS effectively. Immediate preparation for intubation is essential to prevent further deterioration of the client’s respiratory status.
B. Place a tracheostomy tray at the client's bedside: While having a tracheostomy tray available can be important in cases of prolonged respiratory failure, this action is not the immediate priority. The focus should be on ensuring proper airway management and oxygenation first. A tracheostomy is typically considered if the client requires long-term ventilation, but initial intervention for ARDS often involves intubation.
C. Administer IV prophylaxis for thromboembolism: While providing prophylaxis for thromboembolism is important in the overall management of patients at risk, especially in those with limited mobility, it is not the first priority in an acute situation. The immediate need is to address the client’s respiratory distress and ensure proper ventilation.
D. Administer IV prophylaxis for stress ulcers: Providing prophylaxis for stress ulcers is also a relevant consideration, particularly in critically ill patients. However, it is not an urgent action compared to securing the airway and ensuring effective oxygenation. Addressing respiratory failure and maintaining airway patency should take precedence in the acute management of ARDS.

A. Limit oral fluids to minimize labored breathing: This action is not appropriate, as adequate hydration is important for thinning mucus secretions, making it easier for the client to expectorate them. Limiting fluids could lead to thicker secretions, which may worsen the client’s respiratory distress and increase the difficulty of clearing secretions. Therefore, this approach is not suitable for a client with pneumonia and respiratory compromise.
B. Perform pursed-lip breathing to expel trapped carbon dioxide from the alveoli: While pursed-lip breathing can help with exhalation and improve oxygenation, it does not directly address the need to mobilize and clear copious secretions. This technique is beneficial in managing dyspnea and improving ventilation but is not the priority action when the client has significant secretions that need to be cleared.
C. Lie in a low Fowler's position to promote lung expansion: A low Fowler's position (30 degrees) is less effective for promoting lung expansion compared to higher Fowler's positions. Semi-Fowler's (30-45 degrees) or high Fowler's (greater than 45 degrees) positions are more beneficial for improving lung expansion and facilitating breathing in clients with respiratory distress. Therefore, this option does not provide the most effective intervention for the client's condition.
D. Perform hourly incentive spirometry to inflate lungs and mobilize secretions: This is the priority action for the nurse to encourage, as incentive spirometry is specifically designed to help inflate the lungs and improve lung function. It promotes deep breathing, which can enhance ventilation, prevent atelectasis, and facilitate the mobilization of secretions. Regular use of incentive spirometry is essential in managing pneumonia and can significantly improve respiratory outcomes for the client.