1. The nurse is caring for a client Shortness of breath
with suspected acute respiratory
distress syndrome (ARDS). Which Rapid breathing
symptom of ARDS should the nurse
anticipate will appear within 24 to 48 Chest x-ray clear of infiltrates
hours after the initial insult? (Select
all that apply.) Rapid breathing and shortness of
breath are two early symptoms of
Shortness of breath ARDS that manifest in the first day
or two after the initial injury. On chest
Rapid breathing x-ray, no infiltrates will be noted in the
early stages and lung sounds will be
Fluid imbalance clear. Fluid imbalance and abnormal
arterial blood gas levels will be noted
Chest x-ray clear of infiltrates later in the disease process.
Arterial blood gases varying from
normal limits
2. A client is diagnosed with acute res- Systemic sepsis
piratory distress syndrome (ARDS).
The client's spouse asks the nurseMultiple blood transfusions
what caused ARDS. Which etiology
of indirect injury to the lungs should Pancreatitis
the nurse include in the response?
(Select all that apply.) Pancreatitis, systemic sepsis, and
multiple blood transfusions are caus-
Smoke inhalation es of indirect injury to the lungs.
Smoke inhalation and fat embolisms
Systemic sepsis are causes of direct injury to the
lungs.
Fat embolism
Multiple blood transfusions
Pancreatitis
3. The nurse is caring for a client who Notifying the healthcare provider
had an episode of near-drowning 5
, ARDS NCLEX PRACTICE QUESTIONS WITH 100% VERIFIED ANSWERS
days ago. This morning, the nurse Changes in lung sounds after a pul-
noted rhonchi in the lower lung monary injury, like near-drowning,
lobes on auscultation. Which actioncan indicate that the client is devel-
by the nurse is best ? oping acute respiratory distress syn-
drome (ARDS). The nurse should no
Documenting the findings as normal tify the healthcare provider of the
change in the client's condition. In-
Preparing for intubation tubation is not necessary unless
the client is in respiratory distress.
Notifying the healthcare provider Rhonchi on auscultation are not a
normal finding and require the nurse
Monitoring vital signs and oxygen to take action. It is not appropriate
saturation every 2 hours for the nurse to simply monitor the
client without taking action to prevent
a worsening of the client's condition.
4. A client is brought into the emer- Release of chemical mediators
gency department after aspirating
on pureed foods at the long-term After the initial pulmonary injury, suc
care facility. The nurse knows that as aspiration, chemical mediators ar
which physiologic change can trig- released, which damage the alve-
ger acute respiratory distress syn-olar-capillary membrane and trigger
drome? other changes associated with ARDS.
This damage can cause interstitial
Release of chemical mediators (not intracellular) edema and de-
creased (not increased) surfactant
Increased surfactant production production. Destruction of platelets is
not associated with ARDS.
Destruction of extracellular platelets
Intracellular edema
5. The nurse is caring for a client Low PaO2 and high PaCO2
with respiratory acidosis secondary
to end-stage acute respiratory dis-In end-stage ARDS, physiological
tress syndrome (ARDS). Which re- changes in the alveoli prevent CO2
sult should the nurse anticipate on from diffusing across the alveolar
the arterial blood gas? membranes, causing the PaCO2 to
rise and PaO2 to fall. Eventually, res