Author Question: A client with acute respiratory distress syndrome is being mechanically ventilated with positive ... (Read 73 times)

EAugust · **on:** Jul 22, 2018

A client with acute respiratory distress syndrome is being mechanically ventilated with positive end-expiratory pressure (PEEP). Which of the following should the nurse do to ensure an adequate cardiac output for this client?

1. Assess level of consciousness every 4 hours
2. Limit fluids
3. Assess heart and lung sounds every shift
4. Limit moving the client

Question 2

A client with a respiratory rate of 8 breaths per minute has an oxygen saturation of 82. Which of the following is a priority nursing diagnosis for this client?

1. Ineffective Breathing Pattern
2. Decreased Cardiac Output
3. Risk for Infection
4. Risk for Acute Confusion

pallen55 · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

1. Assess level of consciousness every 4 hours

Rationale:
An alteration in level of consciousness with confusion and restlessness are early signs of cerebral hypoxia resulting from a decrease in cardiac output. The nurse should assess the client's level of consciousness every 4 hours to ensure that cerebral hypoxia is not developing. The client should not have fluids limited; an adequate fluid intake is essential to thin pulmonary secretions. Heart and lung sounds should be assessed every 1 to 4 hours. The client should be turned and repositioned frequently with good skin care to prevent the risk for skin breakdown which could lead to infection and sepsis.

Answer to Question 2

1. Ineffective Breathing Pattern

Rationale:
The client has an irregular respiratory pattern of 8 breaths per minute with an oxygen saturation of 82. The nursing diagnosis of priority for this client is ineffective breathing pattern. If this breathing pattern continues without intervention, the client could be at risk for decreased cardiac output and risk for acute confusion. There is not enough information to determine whether the client is or is not at risk for infection.