The nurse is caring for the client diagnosed with ARDS who is on a ventilator. Which interventions should the nurse implement? Select all that apply *1 pointAssess the client’s level of consciousness.Monitor the client’s urine output.Perform passive range-of-motion (ROM) exercises.Maintain intravenous fluids as ordered.Place the client with the head of bed (HOB) flat.
Question
The nurse is caring for the client diagnosed with ARDS who is on a ventilator. Which interventions should the nurse implement? Select all that apply *1 pointAssess the client’s level of consciousness.Monitor the client’s urine output.Perform passive range-of-motion (ROM) exercises.Maintain intravenous fluids as ordered.Place the client with the head of bed (HOB) flat.
Solution
The nurse should implement the following interventions for a client diagnosed with ARDS who is on a ventilator:
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Assess the client’s level of consciousness: This is important to monitor the client's neurological status and response to treatment. Changes in consciousness can indicate worsening of the condition or complications.
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Monitor the client’s urine output: This helps to assess the client's renal function and hydration status. Decreased urine output can indicate poor renal perfusion due to low blood pressure or hypoxia, which are possible complications of ARDS.
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Maintain intravenous fluids as ordered: This ensures the client is receiving the necessary hydration and medications. It's important to monitor for signs of fluid overload, which can worsen ARDS.
The following interventions are not typically recommended for a client with ARDS on a ventilator:
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Perform passive range-of-motion (ROM) exercises: While these exercises can be beneficial for maintaining joint mobility in bedridden patients, they are not a priority for a client with ARDS on a ventilator. The client's respiratory status is the priority.
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Place the client with the head of bed (HOB) flat: This position can actually worsen respiratory status in a client with ARDS. Instead, the head of the bed should be elevated to 30-45 degrees to promote lung expansion and reduce the risk of aspiration.
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