The nurse is caring for a client in acute respiratory distress syndrome (ARDS). The chest x-ray displays evidence of pulmonary edema. The nurse assesses the client for which clinical manifestation?
Wheezes on inspiration
Blood pressure 170/90
Tachypnea
Bradycardia
The Correct Answer is C
A. Wheezes on inspiration: Wheezing is typically associated with obstructive pulmonary conditions, such as asthma or chronic obstructive pulmonary disease (COPD), and is caused by narrowing of the airways. In ARDS, the pathophysiology involves inflammation and fluid accumulation in the alveoli, which leads to impaired oxygen exchange but not typically to wheezing. Instead, crackles or rales (a fine, wet sound) are more commonly heard on auscultation in ARDS, particularly as fluid builds up in the alveoli.
B. Blood pressure 170/90: Although ARDS can be associated with hemodynamic instability, elevated blood pressure (170/90 mmHg) is not a typical finding. In fact, ARDS is more commonly associated with low blood pressure or hypotension, particularly if the client is experiencing shock or is on mechanical ventilation. Elevated blood pressure could suggest another issue, such as pain, anxiety, or the use of medications like vasopressors. It is not directly related to the pulmonary edema seen in ARDS.
C. Tachypnea: Tachypnea, or rapid breathing, is a hallmark clinical manifestation of acute respiratory distress syndrome (ARDS). In ARDS, pulmonary edema (fluid accumulation in the lungs) occurs as a result of damage to the alveolar-capillary membrane, leading to impaired gas exchange. The body attempts to compensate for decreased oxygenation by increasing the respiratory rate, leading to tachypnea. This is an early sign of respiratory distress and often precedes hypoxemia and other more severe manifestations. The nurse should closely monitor for tachypnea, as it can indicate worsening respiratory compromise.
D. Bradycardia: Bradycardia, or a slow heart rate, is not typically associated with ARDS. In fact, tachycardia (an elevated heart rate) is more commonly seen in response to hypoxia, respiratory distress, or as a compensatory mechanism for low blood pressure in critical illness. Bradycardia could indicate other issues such as vagal stimulation, medication effects, or electrolyte imbalances but is not characteristic of ARDS itself. 4o mini
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["3.9"]
Explanation
Step-by-Step Solution:
Convert the toddler's weight from pounds to kilograms.
1 pound is =0.453592 kilograms.
So, 26 pounds = 26 x 0.453592 = 11.793592 kilograms.
Calculate the total daily dose of prednisolone.
The prescribed dose is 2 mg/kg/day.
The toddler weighs 11.793592 kg.
The total daily dose = 2 mg/kg/day x 11.793592 kg = 23.587184 mg/day.
Determine the dose per administration.
The total daily dose is divided into two equal doses (every 12 hours).
The dose per administration = 23.587184 mg/day / 2 = 11.793592 mg per dose.
Calculate the volume of prednisolone syrup to administer.
The available prednisolone syrup is 15 mg/5 ml.
We need to administer 11.793592 mg per dose.
To find the volume, we can set up a proportion:
15 mg / 5 ml = 11.793592 mg / x ml
Cross-multiplying:
15x = 5 x 11.793592
Solving for x:
x = (5 x 11.793592) / 15 = 3.931197 ml
Round the answer to the nearest tenth.
3.9 ml.
Correct Answer is D
Explanation
A. Notify the healthcare provider: While notifying the healthcare provider may eventually be necessary, the first priority is to ensure the client's airway is protected and they are receiving adequate ventilation. The provider can be notified after immediate interventions have been made to stabilize the patient.
B. Insert an oral airway to prevent the client from biting the tube: Inserting an oral airway may be necessary if the client is biting the endotracheal tube, but this is unlikely the first action needed in response to a low-pressure alarm. If the client is not biting the tube, this action will not address the potential causes of the low-pressure alarm, such as a disconnection, leak, or circuit issue.
C. Suction the client and reset the alarm: While suctioning is an important intervention if secretions are the cause of ventilation issues, it is not the first action when the source of the low-pressure alarm is unclear. If a disconnection or leak is the issue, suctioning will not resolve the problem, and the nurse risks delaying appropriate action to address the source of the alarm. The priority is ensuring the client’s ventilation is not compromised, which is best accomplished by using a manual resuscitation bag until the problem is identified and corrected.
D. Disconnect the client from the ventilator and use a manual resuscitation bag: If the source of the low-pressure alarm cannot be identified after checking the client and the ventilator, the first priority is to ensure that the client continues to receive adequate ventilation. Disconnecting the client from the ventilator and using a manual resuscitation bag (Ambu bag) allows for immediate support of the patient's ventilation while the nurse investigates the cause of the alarm. This ensures the client's oxygenation and ventilation needs are met until the problem is resolved. It is critical to address any potential loss of positive pressure or leaks in the ventilator system promptly to avoid respiratory distress or failure.
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