NMNC 4510 - Respiratory EAQ-Questions and All Correct Answers.

NMNC 4510 - Respiratory EAQ-
Questions and All Correct Answers.
When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse would
implement which measure to promote effective airway clearance?

1) Administer sedatives as frequently as possible.

2) Turn the client every 4 hours.

3) Increase ventilator settings every 2 hours.

4) Suction as needed. - Answer 4) Suction as needed.



Rationale:

The nurse should observe the client's need for tracheal/oral/nasal suctioning every 2 hours and
provide adequate suctioning as needed. The nurse should not routinely administer sedatives as
frequently as possible; they should be administered as needed, based on the needs of the
client. The nurse should turn the client every 2 hours, not 4 hours. The nurse should not adjust
vent settings every 2 hours; however, the nurse should check ventilation settings at least once a
shift.



A client is admitted to an intensive care unit with a diagnosis of acute respiratory distress
syndrome (ARDS). The nurse expects which assessment finding?

1) Hypertension

2) Tenacious sputum

3) Altered mental status

4) Slow rate of breathing - Answer 3) Altered mental status



Rationale:

Altered mental status is secondary to cerebral hypoxia, which accompanies ARDS; cognition and
level of consciousness are reduced. Hypotension occurs because of hypoxia. The sputum is not
tenacious, but it may be frothy if pulmonary edema is present. Breathing will be fast and
shallow.



The nurse auscultates fine crackles in a client who has arrived in the emergency department
with respiratory distress. When the nurse is providing information to the client about crackles,
which is appropriate to include?

1) They are indicative of pleural rubbing.

2) They are signs of bronchial constriction.

3) Crackles are located in the smaller air passages.

4) Crackles are heard during respiratory expiration. - Answer 3) Crackles are located in the
smaller air passages.

, Rationale:

Fine crackles (sometimes called rales) are the sounds of fluid bubbling within the smaller
airways and alveoli, usually attributable to pulmonary edema. Pleural rubbing causes a sound
with a grating quality heard over the anterolateral area of the chest; it is attributable to
decreased pleural lubrication. Bronchial constriction causes rhonchi or wheezes. Crackles are
heard during inspiration.



Which medical intervention would the nurse anticipate will be included in the management of a
client with acute respiratory distress syndrome (ARDS)?

1) Chest tube insertion

2) Aggressive diuretic therapy

3) Administration of beta-blockers

4) Positive end-expiratory pressure (PEEP) - Answer 4) Positive end-expiratory pressure (PEEP)



Rationale:

Mechanical ventilation with PEEP will help prevent alveolar collapse and improve oxygenation.
Fluid is not in the pleural space, so chest tube insertion is not indicated. Aggressive diuretic
therapy and administration of beta blockers are contraindicated because of severe hypotension
from the fluid shift into the interstitial spaces in the lungs.



A client develops acute respiratory distress syndrome (ARDS). The nurse assesses the client and
notes signs of pulmonary edema and atelectasis. The findings correspond to which phase of
ARDS?

1) Fibrotic

2) Exudative

3) Reparative

4) Proliferative - Answer 2) Exudative



Rationale:

The exudative (injury) phase of ARDS is the early phase. Alveoli become fluid-filled with
pulmonary shunting and atelectasis. The fibrotic phase of ARDS leads to pulmonary
hypertension and fibrosis. The reparative (resolution) phase starts about 2 weeks after injury; it
is characterized by recovery. If this phase persists for a prolonged time, extensive fibrosis, death,
or chronic disease may result.



A client is experiencing severe acute respiratory distress. Which response would the nurse
expect the client to exhibit?

1) Tremors

2) Anasarca