Acute Respiratory Distress Syndrome
#1. A nurse is assessing a female client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse assesses for which earliest sign of acute respiratory distress syndrome?
The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body.
This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis.
Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles.
#2. patient is being treated for smoke inhalation.He develops severe hypoxia 48 hours after the incident, requiring intubation and mechanical ventilation. Which of the following conditions has he most likely developed?
#3. A male client suffers acute respiratory distress syndrome as a consequence of shock. The client’s condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm?
Conditions that trigger the high-pressure alarm include kinking of the ventilator tubing, bronchospasm or pulmonary embolus, mucus plugging, water in the tube, coughing or biting on the ET tube, and the client’s being out of breathing rhythm with the ventilator.
A disconnected ventilator tube or an ET cuff leak would trigger the low-pressure alarm. Changing the oxygen concentration without resetting the oxygen level alarm would trigger the oxygen alarm.
#4. A nurse is taking pulmonary artery catheter measurements of a male client with acute respiratory distress syndrome. The pulmonary capillary wedge pressure reading is 12mm Hg. The nurse interprets that this readings is:
The normal pulmonary capillary wedge pressure (PCWP) is 8 to 13 mm Hg, and the client is considered to have high readings if they exceed 18 to 20 mm Hg.
The client with acute respiratory distress syndrome has a normal PCWP, which is an expected finding because the edema is in the interstitium of the lung and is noncardiac.
#5. Which of the following would lead the nurse to suspect that a client with a fracture of the right femur may be developing a fat embolus?
Acute respiratory distress syndrome