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 C

Explanation

Discarding the toothbrush and buying another is a way to prevent disease transmission, as the toothbrush can harbor bacteria and reinfect the child or spread the infection to others. The toothbrush should be discarded after 24 hours of antibiotic therapy.

a) Encouraging the child to drink lots of ﬂuids is a way to promote hydration and soothe the throat, but it does not prevent disease transmission. The child should avoid sharing cups or utensils with others and use disposable tissues or paper towels.
b) Taking the child's temperature every 4 hours is a way to monitor fever, but it does not prevent disease transmission. The thermometer should be cleaned and disinfected after each use and not shared with others.
d) Giving the child Tylenol for the pain is a way to relieve discomfort, but it does not prevent disease transmission. The medication should be administered according to the label instructions and not shared with others.

A. "I take this medication once a day in the evening." B. "I rinse my mouth after taking this medication." C. "I use a spacer device when I inhale this medication." D. "I take this medication when I get an asthma attack."

Correct Answer is A

Explanation

Montelukast is an oral leukotriene receptor antagonist that prevents inﬂammation and bronchoconstriction in asthma. It is taken once daily in the evening to prevent nocturnal symptoms and improve morning lung function.

"I rinse my mouth after taking this medication." This is not necessary, as montelukast is not associated with oral thrush or dysgeusia, unlike some inhaled corticosteroids.
"I use a spacer device when I inhale this medication." This is not applicable, as montelukast is not an inhaler, but a tablet or chewable form.
"I take this medication when I get an asthma attack." This is not appropriate, as montelukast is not a rescue medication, but a maintenance medication that should be taken regularly to prevent asthma exacerbations. A short-acting beta2 agonist such as albuterol should be used for acute relief of symptoms.

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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

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