You are providing care to a patient who is being treated for aspiration pneumonia. The client is on a 100% non-rebreather mask. Which finding below is a HALLMARK sign and symptom that the client is developing acute respiratory distress syndrome (ARDS)?
The client is experiencing bradypnea.
The client's PaCO2 is 50 mmHg.
The client's blood pressure is 170/96.
The client's PaO2 remains at 40 mmHg
The Correct Answer is D
A. Bradypnea is not a hallmark sign of ARDS; ARDS typically involves tachypnea or rapid breathing.
B. An elevated PaCO2 indicates hypercapnia but is not specific to ARDS.
C. Elevated blood pressure is not a specific indicator of ARDS.
D. A persistently low PaO2 despite receiving high-flow oxygen (such as from a non-rebreather mask) is a hallmark sign of ARDS, indicating severe hypoxemia and impaired gas exchange.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Subcutaneous nodules are not typically associated with SLE; they are more characteristic of rheumatoid arthritis.
B. Pitting edema of the hands and fingers is more common in conditions such as heart failure or renal disease, rather than SLE.
C. A grey-colored, non-purpuric papular rash is not characteristic of SLE. SLE rashes are usually different in appearance.
D. A dry, red rash across the bridge of the nose and on the cheeks, commonly referred to as a butterfly rash, is a classic manifestation of SLE.
Correct Answer is ["A","B","C","F","G"]
Explanation
A. Temperature: The client has a fever (39.3°C/102.8°F) indicating a potential infection or inflammatory process. This requires immediate follow-up to address the underlying cause of the fever.
B. Blood pressure: The client’s blood pressure is low (84/58 mm Hg on admission and 88/58 mm Hg current), suggesting possible shock or severe dehydration. This finding requires immediate assessment and intervention.
C. Pain level: The client reports increasing back and suprapubic pain, which could be related to a urinary tract infection or other serious condition. Addressing pain and its cause is critical.
D. Adalimumab frequency: The current medication schedule for Adalimumab is less urgent compared to the acute findings. The frequency of this medication does not require immediate follow-up in this context.
E. Heart sounds: No dysrhythmias were noted on the cardiac monitor, so this finding does not require immediate follow-up at this time.
F. WBC count: The WBC count is elevated with leucocyte esterase positive, indicating an infection. This warrants immediate attention to diagnose and treat the infection.
G. Urinalysis: The urinalysis shows cloudy appearance, foul odor, and alkaline pH with positive leucocyte esterase, suggesting a urinary tract infection. This requires immediate follow-up to start appropriate treatment.
H. Hgb & Hct: While important, these values are not provided in the current context. The immediate concerns are more focused on the acute symptoms and signs provided.
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