A client has been diagnosed in the Emergency Department with acute respiratory distress syndrome (ARDS). Which of the following actions should a nurse perform first?
Place a tracheostomy tray at the client’s bedside.
Administer IV prophylaxis for thromboembolism.
Prepare to assist with intubation of the client.
Administer IV prophylaxis for stress ulcers.
The Correct Answer is C
Choice A rationale
Placing a tracheostomy tray at the client’s bedside is not the first action a nurse should take when a client is diagnosed with ARDS. While a tracheostomy may be necessary in some cases, it is not the immediate priority.
Choice B rationale
Administering IV prophylaxis for thromboembolism is important in the management of ARDS, but it is not the first action a nurse should take. The immediate priority is to ensure adequate oxygenation.
Choice C rationale
Preparing to assist with intubation of the client is the first action a nurse should take when a client is diagnosed with ARDS. Intubation and mechanical ventilation are often required to ensure adequate oxygenation in clients with ARDS3.
Choice D rationale
Administering IV prophylaxis for stress ulcers is important in the management of ARDS, but it is not the first action a nurse should take. The immediate priority is to ensure adequate oxygenation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While immunosuppressive drug therapy can facilitate organ rejection, it is not directly related to the development of chronic rhinosinusitis in patients who have undergone organ transplants.
Choice B rationale
Immunosuppressive drug therapy can indeed contribute to chronic rhinosinusitis. Patients who have undergone organ transplants are often on long-term immunosuppressive therapy to prevent organ rejection. This can make them more susceptible to infections, including chronic rhinosinusitis.
Choice C rationale
Chronic rhinosinusitis does not typically damage the transplanted organ. It primarily affects the sinuses and nasal passages.
Choice D rationale
All of the above is not the correct answer because Choices A and C are not accurate in the context of chronic rhinosinusitis in patients who have undergone organ transplants.
Correct Answer is C
Explanation
Choice A rationale
Muffled heart sounds are not a typical sign of pneumothorax. They are more commonly associated with conditions such as pericardial effusion or cardiac tamponade.
Choice B rationale
Sudden hemoptysis, or coughing up blood, is not a typical sign of pneumothorax. It is more commonly associated with conditions such as pulmonary embolism or lung cancer.
Choice C rationale
Absent breath sounds on the affected side is a typical sign of pneumothorax. When air enters the pleural space and causes the lung to collapse, breath sounds may be absent or significantly decreased on the affected side.
Choice D rationale
A declining respiratory rate is not a typical sign of pneumothorax. In fact, a rapid respiratory rate (tachypnea) is more commonly observed in pneumothorax due to the body’s attempt to compensate for the decreased lung capacity.
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