Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
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?
A. Administer low-flow oxygen continuously via nasal cannula.
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. Offer high-protein and high-carbohydrate foods frequently.
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.
C. Place in a prone position.
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.
D. Encourage oral intake of at least 3,000 mL of fluids per day.
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.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Med Surg Proctored Exam 1. Take the full exam now
Full Explanation
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.
Similar Questions
A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take?
A. Disconnect the chest tube from the drainage system during transport.
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. Empty the collection chamber prior to transport.
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. Clamp the chest tube prior to transferring the client to a wheelchair.
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.
D. Keep the drainage system below the level of the client's chest at all times.
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.
Full 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 nurse is providing dietary teaching for a client who has chronic obstructive pulmonary disease. Which of the following instructions should the nurse include?
A. "Use a bronchodilator 1 hour before eating."
A. Administration of a prescribed bronchodilator is typically recommended approximately 30 minutes prior to meals rather than 1 hour. This pharmacological timing helps reduce dyspnea and facilitates easier deglutition and mastication by improving airflow. Using it too early may result in the peak therapeutic effect tapering off before the client finishes the meal.
B. "Eat 3 large meals each day."
B. Consuming 3 large meals each day is contraindicated for clients with chronic obstructive pulmonary disease because a distended stomach can exert upward pressure on the diaphragm. This abdominal crowding significantly increases the work of breathing and leads to early satiety or respiratory distress. Clients are instead encouraged to eat 5 to 6 small, frequent, nutrient-dense meals.
C. "Limit water intake with meals."
C. The nurse should instruct the client to limit water or fluid intake during the actual mealtime to prevent premature gastric distention. Early fullness from fluids reduces the client’s ability to consume essential solid nutrients and calories required to support the increased metabolic demands of labored breathing. Fluids should be consumed between meals to maintain adequate hydration and thin secretions.
D. "Reduce protein intake."
D. Reducing protein intake is inappropriate because these clients require high-protein and high-calorie diets to prevent muscle wasting and support the respiratory muscles. The metabolic cost of breathing in chronic obstructive pulmonary disease is significantly elevated, often leading to a state of malnutrition or cachexia. Protein is vital for tissue repair and maintaining the functional integrity of the diaphragm.
E. None
None
F. None
None
Full Explanation
A. Administration of a prescribed bronchodilator is typically recommended approximately 30 minutes prior to meals rather than 1 hour. This pharmacological timing helps reduce dyspnea and facilitates easier deglutition and mastication by improving airflow. Using it too early may result in the peak therapeutic effect tapering off before the client finishes the meal.
B. Consuming 3 large meals each day is contraindicated for clients with chronic obstructive pulmonary disease because a distended stomach can exert upward pressure on the diaphragm. This abdominal crowding significantly increases the work of breathing and leads to early satiety or respiratory distress. Clients are instead encouraged to eat 5 to 6 small, frequent, nutrient-dense meals.
C. The nurse should instruct the client to limit water or fluid intake during the actual mealtime to prevent premature gastric distention. Early fullness from fluids reduces the client’s ability to consume essential solid nutrients and calories required to support the increased metabolic demands of labored breathing. Fluids should be consumed between meals to maintain adequate hydration and thin secretions.
D. Reducing protein intake is inappropriate because these clients require high-protein and high-calorie diets to prevent muscle wasting and support the respiratory muscles. The metabolic cost of breathing in chronic obstructive pulmonary disease is significantly elevated, often leading to a state of malnutrition or cachexia. Protein is vital for tissue repair and maintaining the functional integrity of the diaphragm.
A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take?
A. Disconnect the chest tube from the drainage system during transport.
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. Empty the collection chamber prior to transport.
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. Clamp the chest tube prior to transferring the client to a wheelchair.
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.
D. Keep the drainage system below the level of the client's chest at all times.
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.
Full 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.