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 B

Explanation

Pursed-lip breathing is a technique that helps clients with COPD to exhale more eﬀectively and prevent air trapping in the lungs. It also reduces dyspnea and improves oxygenation.

a) A low protein diet is not recommended for clients with COPD, as they need adequate protein intake to maintain muscle mass and prevent malnutrition.

c) Fluid restriction is not necessary for clients with COPD, unless they have signs of ﬂuid overload or heart failure. Adequate hydration helps to thin secretions and facilitate expectoration.

d) Early-morning hours are not the best time for exercise and activity for clients with COPD, as they may experience more shortness of breath and fatigue due to diurnal variations in lung function. A better time would be mid-morning or afternoon, after taking bronchodilators and clearing secretions.

A. Immediately notify the provider. B. Clamp the chest tube near the water seal. C. Continue to monitor the client. D. Reposition the client toward the left side.

Correct Answer is C

Explanation

Continuing to monitor the client is the appropriate action for the nurse to take, as a rise in the water seal chamber with client inspiration is a normal and expected finding. The water seal chamber acts as a one-way valve that allows air to exit from the pleural space and prevents air from entering. The water level in this chamber ﬂuctuates with breathing, rising with inspiration and falling with expiration. This indicates that the chest tube system is functioning properly and that there is no air leak.

a) Immediately notifying the provider is not necessary, as a rise in the water seal chamber with client inspiration is not an abnormal or urgent finding. The nurse should only notify the provider if there are signs of complications, such as persistent bubbling in the water seal chamber, which indicates an air leak, or no ﬂuctuation in the water level, which indicates an obstruction or resolution of pneumothorax.
b) Clamping the chest tube near the water seal is not advisable, as it can cause increased pressure in the pleural space and lead to tension pneumothorax. Clamping the chest tube should only be done 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) Repositioning the client toward the left side is not helpful, as it does not aﬀect the water level in the water seal chamber. The nurse should position the client according to their comfort and condition, and avoid placing them ﬂat or on their aﬀected side, as this can impair drainage and ventilation.

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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

Naxlex Comprehensive Predictor Exams

A nurse is developing a plan of care for a client who has COPD. The nurse should include which of the following interventions in the plan?

Correct Answer is B

Explanation

A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration?

Correct Answer is C

Explanation

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