The nurse is caring for a patient who is intubated and receiving positive pressure ventilation to treat acute respiratory distress syndrome (ARDS). Which finding is most important to report to the health care provider?
a. Blood urea nitrogen (BUN) level 32 mg/dL
b. Red-brown drainage from orogastric tube
c. Scattered coarse crackles heard throughout lungs
d. Arterial blood gases: pH 7.31, PaCO2 50, PaO2 68
ANS: B
The nasogastric drainage indicates possible gastrointestinal bleeding and/or stress ulcer, and should be reported. The pH and PaCO2 are slightly abnormal, but current guidelines advocating for permissive hypercapnia indicate that these would not indicate an immediate need for a change in therapy. The BUN is slightly elevated but does not indicate an immediate need for action. Adventitious breath sounds are commonly heard in patients with ARDS.
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Indicate whether the statement is true or false.
A community health nurse is taking care of a client in the community who has severe diarrhea. A nursing diagnosis of fluid volume deficit related to active fluid loss as manifested by diarrhea has been identified for this client
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