A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan?

Administer low-ﬂow oxygen continuously via nasal cannula.

Oﬀer high-protein and high-carbohydrate foods frequently.

Place in a prone position.

Encourage oral intake of at least 3,000 mL of ﬂuids per day.

Answer and Explanation

The Correct Answer is C

Placing the client in a prone position improves oxygenation and ventilation by reducing lung compression, increasing lung expansion, and redistributing blood ﬂow to better match ventilation.

a) Administering low-ﬂow oxygen via nasal cannula is not sufficient for a client with ARDS, who requires
high levels of oxygenation and positive pressure ventilation to prevent alveolar collapse and hypoxemia.
b) Oﬀering high-protein and high-carbohydrate foods frequently is beneficial for a client with ARDS, as it provides adequate nutrition and energy to support lung healing and prevent muscle wasting. However, it is not the priority intervention for improving respiratory function.
d) Encouraging oral intake of at least 3,000 mL of ﬂuids per day is contraindicated for a client with ARDS, who is at risk of ﬂuid overload and pulmonary edema. Fluid intake should be restricted and diuretics should be administered as prescribed to reduce ﬂuid accumulation in the lungs.

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Correct Answer is A

Explanation

Performing the procedure independently is the best indicator of the partner's readiness for the client's discharge, as it demonstrates competence and confidence in suctioning. Suctioning is a skill that requires practice and supervision until mastery is achieved. The nurse should observe and evaluate the partner's performance of suctioning and provide feedback and reinforcement as needed.

b) Attending a class given about tracheostomy care is a good action by the partner, but not the best indicator of readiness for the client's discharge. Attending a class can provide information and education about tracheostomy care, but it does not necessarily translate into skill acquisition or application. The nurse should assess the partner's understanding and retention of the information and provide additional teaching or clarification as needed.
c) Verbalizing all steps in the procedure is a good action by the partner, but not the best indicator of readiness for the client's discharge. Verbalizing all steps in the procedure can help the partner remember and follow the correct sequence and technique of suctioning, but it does not necessarily reﬂect actual performance or ability. The nurse should observe and verify that the partner is doing what they are saying and correct any errors or omissions as needed.
d) Asking appropriate questions about suctioning is a good action by the partner, but not the best indicator of readiness for the client's discharge. Asking appropriate questions about suctioning can show interest and involvement in learning and caring for the client, but it does not necessarily indicate competence or confidence in suctioning. The nurse should answer the partner's questions and provide additional resources or referrals as needed.

A. Dyspnea B. Barrel chest C. Deep respirations D. Clubbing of the fingers E. Bradycardia

Correct Answer is ["A","B","D"]

Explanation

A. Dyspnea:
Dyspnea (shortness of breath) is a common symptom in emphysema due to the destruction of alveolar walls and the resulting reduction in surface area for gas exchange. As the disease progresses, the patient experiences increasing difficulty in breathing, especially during exertion or when the disease becomes more severe.

B. Barrel chest:
A barrel chest is often seen in emphysema, as it results from hyperinflation of the lungs. The increased air trapping due to damaged alveoli causes the chest to expand and become rounded, leading to the characteristic "barrel chest" appearance. This happens because the lungs are constantly overinflated, and the chest wall becomes rigid and rounded as a result.

D. Clubbing of the fingers:
Clubbing of the fingers can occur in chronic respiratory conditions like emphysema due to prolonged hypoxia (low oxygen levels in the blood). This is a compensatory mechanism that involves changes in the nails and fingers. The tips of the fingers become rounded and bulbous over time, and this is commonly associated with long-standing pulmonary diseases.

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A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client with a tracheostomy. The client's partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client's discharge?

Correct Answer is A

Explanation

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Correct Answer is ["A","B","D"]

Explanation

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