NCLEX Qs ACUTE RESPIRATORY DISTRESS SYNDROME Question and answers verified to pass, Exams of Nursing

Download NCLEX Qs ACUTE RESPIRATORY DISTRESS SYNDROME Question and answers verified to pass and more Exams Nursing in PDF only on Docsity! NCLEX Q"s ACUTE RESPIRATORY DISTRESS SYNDROME (ARDS) A nurse is assessing 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? A. Bilateral wheezing B. Inspiratory crackles C. intercostal retractions D. Increased respiratory rate - correct answer D. Increased respiratory rate Rationale: The earliest detectable sign of ARDS is an increased respiratory rate, which can begin from 1-96 hours after the initial injury to the body. This is followed by increasing dyspnea., air hunger, retractions of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles. Although ARDS may result from direct lung injury or indirect lung injury as a result of systemic inflammatory response syndrome (SIRS), the nurse is aware that ARDS is most likely to occur in the patient with a host insult resulting from A. Sepsis B. Oxygen toxicity C. Prolonged hypotension D. Cardiopulmonary bypass - correct answer A. sepsis Rationale: Although ARDS may occur in the patient who has virtually any severe illness and may be both a cause and a result of systemic inflammatory response syndrome (SIRS), the most common precipitating insults of ARDS are sepsis, gastric aspiration, and severe massive trauma. Prone positioning is considered for a patient with ARDS who has not responded to other measures to increase PaO2. The nurse knows that this strategy will A. increase the mobilization of pulmonary secretions. B. decrease the workload of the diaphragm and intercostal muscles. C. promote opening of atelectatic alveoli in the upper portion of the lung. D. promote perfusion of nonatelectatic alveoli in the anterior portion of the lung. - correct answer D. Promote perfusion of nonatelectatic alveoli in the anterior portion of the lung. Rationale: When a patient with ARDS is supine, alveoli in the posterior areas of the lung are dependent and fluid-filled and the heart and mediastinal contents place more pressure on the lungs, predisposing to atelectasis. If the patient is turned prone, air-filled nonatelectatic alveoli in the anterior portion of the lung receive more blood and perfusion may be better matched to ventilation, causing less V/Q mismatch. Lateral rotation therapy is used to stimulate postural drainage and help mobilize pulmonary secretions. What are the primary pathophysiologic changes that occur in the injury or exudative phase of ARDS (select all that apply)? A. Atelectasis B. Shortness of breath C. Interstitial and alveolar edema D. Hyaline membranes line the alveoli E. Influx of neutrophils, monocytes, and lymphocytes - correct answer answer A,C,D Rationale: . The injury or exudative phase is the early phase of ARDS when atelectasis and interstitial and alveoli edema occur and hyaline membranes composed