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.
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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Related Questions
Correct Answer is A
Explanation
Using a bronchodilator 1 hour before eating can help reduce dyspnea and improve appetite for a client who has COPD. It can also facilitate oxygen delivery to the tissues and prevent hypoxia.
b) Eating 3 large meals each day is not recommended for a client who has COPD, as it can cause abdominal distension and increase pressure on the diaphragm, leading to dyspnea and fatigue. A better option is to eat 5 to 6 small meals throughout the day.
c) Limiting water intake with meals is not advisable for a client who has COPD, as it can cause dehydration and increase the viscosity of secretions, making them harder to expectorate. A better option is to drink at least 2 L of fluids per day, preferably between meals.
d) Reducing protein intake is not beneficial for a client who has COPD, as protein is essential for maintaining muscle mass and strength, especially of the respiratory muscles. A better option is to increase protein intake to at least 1.2 g/kg of body weight per day.
Correct Answer is C
Explanation
Agitation is a sign of hypoxemia, as the brain is deprived of oxygen and becomes irritable and restless.
The other options are not correct because:
- Nausea is not a specific manifestation of hypoxemia, as it can have many other causes such as medication side effects, gastrointestinal disorders, or anxiety.
- Dysphagia is difficulty swallowing, which is not related to hypoxemia or asthma. It can be caused by neurological, muscular, or structural problems in the throat or esophagus.
- Hypotension is low blood pressure, which is not a typical manifestation of hypoxemia or asthma. It can be caused by dehydration, blood loss, shock, or heart failure.
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