ATI RN
Health And Safety for Clients Questions
Question 1 of 5
The nurse suspects the client may be developing ARDS. Which assessment data confirm the diagnosis of ARDS?
Correct Answer: A
Rationale: The correct answer is A because in ARDS, the lungs are unable to oxygenate the blood effectively despite high levels of supplemental oxygen. This results in low arterial oxygen levels even when giving a high concentration of oxygen. Choice B is incorrect because dyspnea, tachycardia, and anxiety are common symptoms of ARDS but do not confirm the diagnosis. Choice C is incorrect because clear breath sounds and a pulse oximeter reading of 95% do not confirm ARDS, as ARDS is characterized by severe oxygenation impairment. Choice D is incorrect because jugular vein distention and frothy sputum are not specific indicators of ARDS, although they may be present in some cases.
Question 2 of 5
The nurse notes a patient with ARDS has a rising central venous pressure (CVP) and increasing oxygen requirements. What is the priority action?
Correct Answer: B
Rationale: The correct answer is B: Assess for fluid overload and manage diuresis if indicated. In ARDS, increasing CVP and oxygen requirements may indicate fluid overload contributing to the respiratory distress. Diuresis can help reduce fluid volume, improve oxygenation, and decrease the workload on the heart. Increasing oxygen flow rate (A) may help temporarily but doesn't address the underlying issue of fluid overload. Notifying the physician about worsening hypoxemia (C) is important but addressing fluid overload is the immediate priority. Immediate intubation (D) may be necessary in severe cases, but addressing fluid overload should be attempted first.
Question 3 of 5
Which action should the nurse take first when a patient with ARDS develops a high-pressure alarm on the ventilator?
Correct Answer: A
Rationale: The correct action is to check for kinks or obstructions in the ventilator tubing first because a high-pressure alarm indicates a potential issue with airflow, which can lead to decreased oxygenation and ventilation. By ensuring the tubing is clear, the nurse can address the immediate problem and potentially prevent further complications. Auscultating lung sounds for a pneumothorax can be important but is not the priority in this situation. Suctioning the endotracheal tube for secretions may help in some cases but should not be the first action when a high-pressure alarm occurs. Notifying the respiratory therapist is important, but resolving the potential obstruction in the ventilator tubing should be the initial step to ensure the patient's safety and optimal ventilation.
Question 4 of 5
Which intervention is most likely to prevent or limit barotrauma in the patient with ARDS who is mechanically ventilated?
Correct Answer: B
Rationale: The correct answer is B: Use of permissive hypercapnia. In ARDS, permissive hypercapnia allows for lower tidal volumes and pressures, reducing the risk of barotrauma. Decreasing PEEP (A) can worsen oxygenation. Increasing tidal volume (C) can exacerbate lung injury. Positive pressure ventilation (D) is necessary but can lead to barotrauma if not carefully managed.
Question 5 of 5
A Client has been intubated and placed on a volume-cycled mechanical ventilator. The nurse carefully assess the client for findings associated with a risk associated with this type of ventilator. What is the risk?
Correct Answer: D
Rationale: The correct answer is D: Barotrauma. Barotrauma refers to lung injury caused by excessive pressure during mechanical ventilation. With a volume-cycled ventilator, there is a risk of delivering high tidal volumes at high pressures, leading to barotrauma. Hypoventilation (A), hypercapnia (B), and respiratory acidosis (C) are outcomes of inadequate ventilation, but they are not the specific risk associated with a volume-cycled ventilator.