The nurse develops a care plan for a critically ill client with acute respiratory distress syndrome (ARDS) who is on a mechanical ventilator. What is the priority nursing diagnosis (ND)?

Question

Quizplus · Accepted Answer

ARDS involves damage to the alveolar-capillary membrane, the blood-gas barrier across which oxygen diffuses into the alveoli. When the membrane is damaged, the alveoli collapse and fluid leaks into the alveolar space and impairs gas exchange. Impaired gas exchange related to alveolar-capillary changes and ventilation-perfusion imbalance is the priority ND for a client with ARDS. (Option A) Imbalanced nutrition (less than body requirements) related to increased metabolic needs and inability to ingest foods due to endotracheal intubation, is an appropriate ND for the client with ARDS. However, it does not pose the greatest threat to survival and is not the priority ND. (Option C) Impaired tissue (integumentary) related to altered circulation, immobility, and nutritional deficits is an appropriate ND for the client with ARDS. However, it does not pose the greatest threat to survival and is not the priority ND. (Option D) Risk for infection related to the presence of an endotracheal tube, frequent suctioning, intravenous devices, and indwelling catheters is an appropriate ND for the client with ARDS. However, it does not pose the greatest threat to survival and is not the priority ND. Educational objective: ARDS involves damage to the alveolar-capillary membrane, resulting in fluid leakage into the alveolar space. Impaired gas exchange related to alveolar-capillary changes and ventilation-perfusion imbalance is an appropriate ND for a client with ARDS.

The Nurse Develops a Care Plan for a Critically Ill