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 B
Explanation
A. An urge to void despite an indwelling catheter may be a normal postoperative sensation due to bladder irritation, but it is not a clear indication of a complication.
B. Output of burgundy colored urine can indicate significant bleeding or a complication such as hemorrhage, which requires immediate attention.
C. A pulse rate of 88/min is within normal limits and does not suggest a postoperative complication.
D. An oral temperature of 38.2° C (100.76° F) is slightly elevated but not uncommon immediately after surgery; it may be monitored but does not immediately indicate a serious complication.
Correct Answer is D
Explanation
A. Notifying the provider is important if initial interventions do not resolve the issue, but it is not the first action to take.
B. Adjusting the rate of the bladder irrigant may help, but first, it is essential to ensure that there is no mechanical obstruction in the tubing.
C. Irrigating the catheter can help clear any blockages, but the first step is to check for any kinks or obvious obstructions in the tubing.
D. Checking the tubing for kinks is the first action as it is a common and easily rectifiable cause of urinary catheter drainage issues. This should be done before other interventions.
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