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What are the key nursing interventions for a patient experiencing acute respiratory distress syndrome (ARDS)?
- A. Positioning the patient in a prone position
- B. Monitoring vital signs and lung sounds
- C. Preparing for mechanical ventilation
- D. Administering supplemental oxygen
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.
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A nurse is caring for a client who has an indwelling urinary catheter and a prescription for a urine specimen for culture and sensitivity. Which of the following actions should the nurse take?
- A. Wipe the area around the needleless port with sterile water
- B. Insert the syringe into the needleless port at a 60-degree angle
- C. Withdraw 3 to 5 ml of urine from the port
- D. Don sterile gloves
Correct Answer: C
Rationale: The correct action for the nurse to take is to withdraw 3 to 5 ml of urine from the port for an accurate culture and sensitivity test. Wiping the area around the needleless port with sterile water (Choice A) is not necessary when obtaining a urine specimen. Inserting the syringe into the needleless port at a 60-degree angle (Choice B) is incorrect as it does not align with the correct procedure for obtaining a urine specimen. Donning sterile gloves (Choice D) is a good practice but not the immediate action required for obtaining a urine specimen.
After a case manager completes a history and physical assessment for a client with COPD, which of the following actions should the case manager take next?
- A. Call the provider with a list of client concerns.
- B. Identify the client's current health needs.
- C. Compile a list of community resources for the client.
- D. Refer the client to a COPD support group.
Correct Answer: A
Rationale: After completing a history and physical assessment for a client with COPD, the next step for the case manager should be to call the provider with a list of client concerns. This is crucial as the provider needs to be informed about any issues or changes in the client's health status to ensure appropriate management. Identifying the client's current health needs, as mentioned in option B, is important but would typically follow after communicating the client's concerns to the provider. Compiling a list of community resources (option C) and referring the client to a COPD support group (option D) are also valuable actions but are not the immediate next steps after completing the assessment.
A client who has been having frequent tonic-clonic seizures is being admitted by a nurse. Which of the following actions should the nurse add to the client's plan of care?
- A. Apply restraints
- B. Use soft wristbands
- C. Wrap blankets around side rails
- D. Administer sedatives
Correct Answer: C
Rationale: The correct action the nurse should add to the client's plan of care is to wrap blankets around side rails. This helps prevent injury during seizures by providing a cushioned surface against the hard rails. Applying restraints (Choice A) is not recommended as it can cause harm during a seizure. Using soft wristbands (Choice B) may not provide adequate protection against injury. Administering sedatives (Choice D) is not typically indicated for managing tonic-clonic seizures as they require specific anti-seizure medications.
What are the key components of a pain assessment in a postoperative patient?
- A. Checking the effectiveness of pain interventions
- B. Observing for nonverbal signs of pain like grimacing
- C. Assessing the location, duration, and quality of the pain
- D. Asking the patient to rate their pain on a scale of 1-10
Correct Answer: A
Rationale: The correct answer is A because in a postoperative patient, it is crucial to evaluate the effectiveness of the pain interventions that have been implemented. While choices B, C, and D are important aspects of a pain assessment, they do not specifically address the key component of assessing the effectiveness of the interventions applied postoperatively.
A healthcare professional is assessing a client 15 minutes after administering morphine sulfate 2 mg via IV push. The healthcare professional should identify which of the following findings as an adverse effect of the medication?
- A. Drowsy but responsive when her name is called
- B. SaO2 94%
- C. Respiratory rate 8/min
- D. Pain level of 6 on a scale from 0 to 10
Correct Answer: C
Rationale: A respiratory rate of 8/min is a significant adverse effect of morphine that indicates respiratory depression, which requires immediate intervention to prevent further complications. The client may not be effectively ventilating, leading to hypoxia and respiratory acidosis. Option A is less concerning as being drowsy but responsive is a common side effect of morphine. Option B indicates decreased oxygen saturation, which is also a concern but not as severe as respiratory depression. Option D is important but not as critical as the potential respiratory compromise indicated by the low respiratory rate.