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 D

Explanation

Keeping the drainage system below the level of the client's chest prevents backﬂow of ﬂuid or air into the
pleural space and maintains negative pressure in the system.

a) Disconnecting the chest tube from the drainage system during transport is dangerous and can cause pneumothorax, infection, or bleeding. The chest tube should remain connected to the drainage system at all times unless ordered by the provider.
b) Emptying the collection chamber prior to transport is unnecessary and can interfere with accurate measurement of drainage. The collection chamber should be emptied only when it is full or at the end of each shift.
c) Clamping the chest tube prior to transferring the client to a wheelchair is contraindicated and can cause tension pneumothorax, as it prevents air from escaping the pleural space. The chest tube should only be clamped for a brief period when changing the drainage system or checking for air leaks, and only with a provider's order.

A. Increase the client's wall suction. B. Reposition the client. C. Clamp the client's chest tube. D. Strip the client's chest tube.

Correct Answer is B

Explanation

Repositioning the client is the appropriate action for the nurse to take, as chest burning may indicate that the chest tube is kinked, twisted, or compressed, which can impair drainage and ventilation. The nurse should gently move the client to a diﬀerent position and check that the chest tube is not bent or occluded by clothing, bedding, or furniture. The nurse should also ensure that there are no dependent loops or coils in the tubing and that it is secured to prevent dislodgment.

a) Increasing the client's wall suction is not advisable, as it can cause increased negative pressure in the pleural space and lead to tension pneumothorax. Increasing the wall suction does not aﬀect the patency of the chest tube or the drainage of air or ﬂuid from the lung. The nurse should maintain the wall suction at the prescribed level and monitor for any changes in the suction chamber.
c) Clamping the client's chest tube is not advisable, as it can cause air or ﬂuid accumulation in the pleural space and lead to tension pneumothorax. Clamping the chest tube does not relieve chest burning or improve drainage or ventilation. The nurse should only clamp the chest tube for a brief period of time and under specific circumstances, such as changing the drainage system, assessing for an air leak, or preparing for chest tube removal.
d) Stripping the client's chest tube is not advisable, as it can cause increased negative pressure in the pleural space and lead to tissue damage or bleeding. Stripping the chest tube involves applying manual pressure along the tubing to force out any clots or debris that may obstruct drainage. However, this practice is not recommended, as it can cause more harm than good. The nurse should only milk the chest tube gently and intermittently if ordered by the provider and if there is evidence of obstruction.

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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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Correct Answer is D

Explanation

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Correct Answer is B

Explanation

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