what are the key nursing interventions for a patient experiencing acute respiratory distress syndrome ards
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Nursing Elites

ATI RN

RN ATI Capstone Proctored Comprehensive Assessment 2019 B

1. What are the key nursing interventions for a patient experiencing acute respiratory distress syndrome (ARDS)?

Correct answer: A

Rationale: The correct answer is A: Positioning the patient in a prone position. Prone positioning is a key nursing intervention for patients with acute respiratory distress syndrome (ARDS) as it helps improve oxygenation by allowing better lung ventilation. Choice B, monitoring vital signs and lung sounds, is important but not a key intervention specific to ARDS. Choice C, preparing for mechanical ventilation, may be necessary in severe cases of ARDS but is not a primary nursing intervention. Choice D, administering supplemental oxygen, is a common supportive measure but is not specific to ARDS interventions.

2. A nurse is assessing a client who has heart failure and is taking digoxin. The nurse should monitor the client for which of the following manifestations as an indication of digoxin toxicity to report to the provider?

Correct answer: B

Rationale: The correct answer is B: Vomiting. Vomiting is a common sign of digoxin toxicity and should be reported to the healthcare provider. Diarrhea (Choice A) is a more common side effect of digoxin but not typically associated with toxicity. Ringing in the ears (Choice C) is a potential sign of toxicity; however, vomiting is a more immediate concern. Dizziness (Choice D) can occur with digoxin use but is not a specific indicator of toxicity.

3. A nurse is preparing medications for a client via nasogastric tube. What should the nurse do before administering the medications?

Correct answer: B

Rationale: Before administering medications through a nasogastric tube, the nurse should administer them one after the other without flushing. Flushing the tube with water should be done before and after each medication to prevent any interactions and ensure each medication is delivered effectively. The correct answer is not to administer all medications at once (choice A) as this can lead to potential drug interactions. Crushing all medications and mixing them together (choice C) is incorrect as each medication should be given separately to maintain their individual efficacy. Administering medications in liquid form only (choice D) is limiting and may not be suitable for all types of medications that need to be administered.

4. A nurse is preparing to administer medication to a client by nasogastric tube. What should the nurse do first?

Correct answer: B

Rationale: The correct answer is B: Check the tube placement before administering any medication. Before administering medication through a nasogastric tube, the nurse must first verify the tube's correct placement to ensure the medication reaches the stomach and to prevent complications such as aspiration. Options A, C, and D are incorrect because administering medication without confirming proper tube placement can lead to serious consequences for the client.

5. A nurse is caring for a client who had a total thyroidectomy and has a serum calcium level of 7.6 mg/dL. Which of the following findings should the nurse expect?

Correct answer: C

Rationale: The correct answer is C: Tingling of the extremities. Tingling is a common symptom of hypocalcemia, which is expected with low calcium levels after a thyroidectomy. Option A, shortened QT intervals, is associated with hypercalcemia rather than hypocalcemia. Option B, hypoactive deep tendon reflexes, is not typically related to hypocalcemia. Option D, constipation, is not a common finding associated with low calcium levels.

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