# An adult with sepsis is intubated for acute hypoxemic respiratory failure. Chest imaging shows new bilateral opacities, the PaO2/FiO2 ratio is 180 on PEEP 10 cm H2O, and cardiac failure or fluid overload does not fully explain the findings. Which interventions are appropriate for acute respiratory distress syndrome (ARDS)? Select all that apply.

> source: MyMerci (mymerci.kr)  
> url: https://mymerci.kr/pages/nclex_q.php?qn_id=369796&lang=en  
> language: en  
> subject: Medical Emergencies  
> category: PA

## Question

An adult with sepsis is intubated for acute hypoxemic respiratory failure. Chest imaging shows new bilateral opacities, the PaO2/FiO2 ratio is 180 on PEEP 10 cm H2O, and cardiac failure or fluid overload does not fully explain the findings. Which interventions are appropriate for acute respiratory distress syndrome (ARDS)? Select all that apply.

1

Confirm an acute, noncardiogenic hypoxemic lung-injury pattern using the current ARDS diagnostic criteria

2

Elevate the head of the bed, provide oral hygiene and subglottic drainage, and assess daily readiness to reduce sedation and ventilator support

3

For persistent moderate-to-severe hypoxemia despite optimized ventilation, use prolonged prone positioning for about 12 to 16 hours per day

4

Titrate PEEP and FiO2 to the prescribed oxygenation goal and monitor pH during protocol-directed permissive hypercapnia

5

Continue routine crystalloid after shock resolves to maintain central venous pressure above 12 mmHg, regardless of current perfusion findings

6

Use low-tidal-volume ventilation based on predicted body weight and keep plateau pressure at or below 30 cm H2O

## Explanation

The findings support ARDS: acute bilateral pulmonary opacities and hypoxemia are not primarily explained by hydrostatic edema (Choice 1). Lung-protective ventilation uses low tidal volumes based on predicted body weight and limits plateau pressure to 30 cm H2O or less (Choice 6). Prolonged prone positioning is recommended for persistent moderate-to-severe ARDS, with protocols commonly using at least 12 to 16 hours per day (Choice 3). PEEP, FiO2, and permissive hypercapnia are managed through a protocol with oxygenation and pH targets individualized to the client (Choice 4). Head elevation, oral hygiene, subglottic secretion management when available, and daily assessment for sedation reduction and ventilator liberation reduce ventilator complications; routine oral chlorhexidine and stress-ulcer or thrombosis prophylaxis should not be mislabeled as a universal pneumonia bundle (Choice 2). After shock is controlled, avoid a fixed high central venous pressure or unnecessary liberal fluid administration (Choice 5).

## In-depth explanation

Clinical Judgment
ARDS care is bundled — diagnose with the Berlin criteria, then layer evidence-based interventions: low tidal volume + prone + conservative fluid + PEEP titration + VAP bundle. Each component independently reduces mortality.

Memory Tip
ARDSnet vent settings = 6 mL/kg PBW, plateau ≤ 30 cm H2O, SpO2 88–95%. Prone trigger = P/F < 150 for ≥ 16 hours per day (PROSEVA).

KR vs US
Korean ICUs rapidly adopted prone positioning during COVID-19, but conservative fluid strategy is still under-implemented. NCLEX-RN expects the nurse to know that ARDS fluid management is restrictive, not liberal, and that prone positioning is a nursing-led intervention requiring proper team coordination.

## Clinical scenario

Clinical Practice Guide
ATS/ESICM/SCCM 2017 ARDS guidelines and the Berlin Definition (2012) anchor diagnosis and management. Key trials: ARDSnet (low tidal volume), PROSEVA (prone), FACTT (conservative fluid). Severe ARDS (P/F ≤ 100) may need neuromuscular blockade, recruitment maneuvers, and ECMO referral.

Caution
Common NCLEX traps: large tidal volumes (10 mL/kg), supine flat positioning, liberal fluids to chase blood pressure, and 100 percent FiO2 without PEEP titration. Remember: high pressures and high volumes injure lungs — protect them at every turn.

## Key concepts

- **Berlin Criteria for ARDS** — The 2012 international consensus definition of ARDS. Requires all of: onset within 1 week of a known clinical insult, bilateral opacities on chest imaging not fully explained by effusions or atelectasis, respiratory failure not fully explained by cardiac failure or fluid overload, and PaO2/FiO2 ratio measured on PEEP ≥ 5 cm H2O. Severity: mild (P/F 201–300), moderate (101–200), severe (≤ 100). NCLEX exam tip: PEEP ≥ 5 is required for the ratio to count.
- **Lung Protective Ventilation (ARDSnet)** — Mechanical ventilation strategy that reduces mortality in ARDS by limiting volutrauma and barotrauma. Tidal volume 4–8 mL/kg of predicted body weight (target 6), plateau pressure ≤ 30 cm H2O, PEEP/FiO2 titration table to keep SpO2 88–95 percent, and permissive hypercapnia (pH 7.20–7.30 acceptable). NCLEX exam tip: predicted body weight is calculated from height and sex, not actual weight, to avoid over-volume in obese clients.
- **Prone Positioning** — Placing the intubated ARDS client face-down to recruit dorsal alveoli, improve V/Q matching, and reduce mortality. Indicated for moderate-severe ARDS with PaO2/FiO2 < 150 for at least 16 hours per day (PROSEVA trial). Nursing priorities: secure ETT and lines, eye and pressure-point care, scheduled position changes, and team-based pronation. NCLEX exam tip: prone is a nursing-coordinated intervention requiring at least 4 staff for safe execution.

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