A nurse is caring for a client with ARDS. Which of the following clinical indicators would signify that this client is in respiratory failure? Select all that apply.

• A pCO2 level over 50 mmHg
• An ABG pH level of 7.35
• Pulse oximetry of 94% on room air
• A respiratory rate greater than 16 breaths per minute
• A PaO2 level below 60 mmHg

A nurse is caring for a client who is in respiratory distress because of ARDS. Which of the following conditions would most likely be present in this client?

• Disturbed personal identity
• Problems with thermoregulation
• Anuria
• Lack of tissue perfusion

A nurse must position the client prone after a diagnosis of acute respiratory distress syndrome (ARDS). Which of the following is a benefit of using this position? Select all that apply.

• Mobilization of secretions
• Decreased pleural pressure
• Decreased atelectasis
• Increased response to corticosteroid therapy
• Reduced need for endotracheal intubation

A 25-year-old client in the ICU is being treated for acute respiratory distress syndrome (ARDS). The client is on a ventilator and requires 80 percent FiO2. Which information would the nurse most likely need to report about the client to the respiratory therapist assigned to this case?

• The client needs an arterial blood gas drawn
• The client needs endotracheal suctioning
• The client needs more oxygen because of O2 saturations
• The client needs a hemoglobin level drawn

A nurse in the ICU is caring for a client that has been ventilated for 2 weeks due to Acute Respiratory Distress Syndrome (ARDS). The client’s FiO2 has been at 60% for the last 48 hours. What is the nurse’s immediate priority concern at this time?

• Ventilator associated pneumonia
• Fluid retention
• Oxygen toxicity
• Risk for sepsis

A nurse is using a non-rebreather mask to administer oxygen to an adult client who is in respiratory distress. Which nursing intervention should the nurse employ when using this type of oxygen delivery device?

• Slowly increase the amount of oxygen administered over the first hour
• Ensure that the mask fits well over the mouth and nose
• Avoid administering solid food and only give liquids with this type of mask
• Assess the client's skin and hair every 4 hours

A nurse is caring for a client who was brought into the ED complaining of chest pain and difficulty breathing. Which of the following vital sign measurements most likely indicate that the client is struggling with dyspnea?

• Respiratory rate greater than 25/min
• Concave abdomen
• Dry, hot skin
• Oxygen saturation of 95%

A client is suffering from fluid overload due to a history of severe liver disease. Which of the following interventions would be the highest priority for this client?

• Weigh the client daily
• Elevate the lower extremities to reduce edema
• Monitor for heart arrhythmias and the presence of crackles on auscultation
• Check skin regularly for signs of skin breakdown

A nurse is assessing a client for fluid volume overload. The nurse knows that which of the following orders should be implemented to determine if the client is in fluid overload?

• Place the client on 5L O2 nasal cannula
• Count client respirations
• Draw blood cultures
• Take the client to radiology for chest x-ray 

The nurse just received reports on the following four clients. Which client should the nurse see first? 1) A client who was admitted for sepsis with vasopressors infusing 2) A client who was admitted for respiratory distress with normal saline infusing and a respiratory rate of 20 3) A client who was admitted for a non-ST elevated MI (NSTEMI) with heparin infusing 4) A client who was admitted for a urinary tract infection with antibiotics infusing

• A client who was admitted for a urinary tract infection with antibiotics infusing
• A client who was admitted for respiratory distress with normal saline infusing and a respiratory rate of 20
• A client who was admitted for sepsis with vasopressors infusing
• A client who was admitted for a non-ST elevated MI (NSTEMI) with heparin infusing