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. Suctioning the nostril is not appropriate as it could exacerbate potential cerebrospinal fluid (CSF) leakage or cause further injury.
B. Asking the client to blow their nose could increase intracranial pressure and potentially worsen a skull fracture or CSF leak.
C. While notifying the physician is important, the initial step should be to determine whether the clear drainage is CSF, which has specific implications.
D. Testing the drainage for glucose is crucial because a positive glucose test indicates that the fluid is likely CSF, which can signal a skull fracture and possible brain injury. This finding requires immediate medical evaluation to manage potential complications like infections or worsening of the fracture.
Correct Answer is A
Explanation
A. Fresh flowers and potted plants should be avoided in the room of a client with neutropenia because they can harbor bacteria and fungi, which can increase the risk of infection.
B. Oral fluid intake should be encouraged throughout the day to maintain hydration and support overall health, rather than restricting it to between meals.
C. While activities that could result in bleeding should be managed cautiously, the primary concern for a client with neutropenia is the risk of infection, not bleeding.
D. Restricting all visitors is not necessary unless directed by specific protocols; rather, visitors should follow strict hygiene practices to prevent infection.
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