A patient with ARDS is on a mechanical ventilator and is becoming increasingly restless with a heart rate of 128
The SaO2 is 88% and the ventilator settings are FiO2 50%; PEEP 8 cm; AC 10 with a total respiratory rate of 30; and a tidal volume of 700 mL. There are coarse rhonchi audible in all lung fields. The appropriate nursing action would be to: 1. Hyperoxygenate with 100% oxygen and suction the patient.
2. Administer the ordered neuromuscular blockade medications.
3. Increase the FiO2 to 60% and tidal volume to 750 mL for 2 minutes.
4. Increase the PEEP to 10 cm and sedate the patient.
1
Rationale 1: The patient needs to be suctioned as evidenced by the symptoms of hypoxia–low SaO2 and tachycardia. The presence of rhonchi is most likely obstructing the airway.
Rationale 2: Paralyzing the patient is not appropriate because there are indications suctioning needs to be done. Paralyzing agents are used for ventilator synchrony.
Rationale 3: Changing ventilator settings are not indicated at this time.
Rationale 4: Sedation or changing the PEEP is not appropriate.
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