Exam 2: ARDS/RF (NCLEX) questions and answers graded A+

Exam 2: ARDS/RF (NCLEX)The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress sysndrome? a. Bilateral wheezing b. Inspiratory crackles c. Intercostal retractions d. Increased respiratory rate - correct answer D When assessing a 22-year-old patient who required emergency surgery and multiple transfusions 3 days ago, the nurse finds that the patient looks anxious and has labored respirations at a rate of 38 breaths/min. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most appropriate? A.) Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes. B.) Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs. C.) Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation. D.)Switch the patient to a nonrebreather mask at 95% to 100% fraction of inspired oxygen (FIO2) and call the health care provider to discuss the patient's status. - correct answer D The patient's history and symptoms suggest the development of acute respiratory distress syndrome (ARDS), which will require intubation and mechanical ventilation to maintain oxygenation and gas exchange. The HCP must be notified so that appropriate interventions can be taken. Application of a nonrebreather mask can improve oxygenation up to 95 to 100%. The maximum oxygen delivery with a nasal cannula is an Fio2 of 44%. This is achieved with the oxygen flow at 6 L/min, so increasing the flow to 10 L/min will not be helpful. Helping the patient to cough and deep breathe will not improve the lung stiffness that is causing his respiratory distress. Morphine sulfate will only decrease the respiratory drive and further contribute to his hypoxemia.