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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

Choice A rationale
While it is important to monitor oxygen use to prevent hypoxia and hypercapnia, taking breaks from oxygen use is not typically recommended for clients with COPD. These clients often require supplemental oxygen to maintain adequate oxygen saturation.
Choice B rationale
Maintaining a low flow rate of oxygen is crucial in clients with COPD. These clients are often “CO2 retainers,” and administering a high concentration of oxygen can suppress their respiratory drive, leading to further CO2 retention and respiratory distress.
Choice C rationale
While it is important to assess for signs of skin breakdown in clients receiving oxygen therapy, this is not the priority when administering nasal oxygen to a client with COPD38.
Choice D rationale
Clients should not adjust their oxygen flow rate without medical supervision. Increasing the oxygen flow rate can lead to hyperoxia, which can be harmful, especially in clients with COPD who are CO2 retainers.

A. Intermittent oxygen use. B. Clubbing of fingers. C. Pursed-lip breathing. D. Prolonged exhalation. E. Dyspnea on exertion.

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

Explanation

Choice A rationale
Intermittent oxygen use is common in clients with COPD, especially during activities that increase oxygen demand or during acute exacerbations.
Choice B rationale
Clubbing of fingers is a sign of chronic hypoxia, which can occur in advanced COPD78.
Choice C rationale
Pursed-lip breathing is a technique often used by clients with COPD to improve exhalation and reduce breathlessness.
Choice D rationale
Prolonged exhalation is a common finding in COPD due to airway obstruction and air trapping.
Choice E rationale
Dyspnea on exertion is a common symptom in COPD due to decreased lung function and increased work of breathing.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD). Which precaution should the nurse prioritize when administering nasal oxygen therapy to the client?

Correct Answer is B

Explanation

A nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) who is being evaluated for a lung transplant. What findings should a nurse expect when performing an initial physical assessment on a client diagnosed with COPD? Select all that apply.

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

Explanation

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