The nurse is caring for a child with acute respiratory distress syndrome (ARDS) associated with sepsis. What nursing action should be included in the care of the child?
a. Force fluids.
b. Monitor pulse oximetry.
c. Institute seizure precautions.
d. Encourage a high-protein diet.
ANS: B
Careful monitoring of oxygenation and cardiopulmonary status is an important evaluation tool in the care of the child with ARDS. Maintenance of vascular volume and hydration is important and should be done parenterally. Seizures are not a side effect of ARDS. Adequate nutrition is necessary, but a high-protein diet is not helpful.
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