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?

Question

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

Answer 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.