Nur237 test 3 with Complete Rationales
100% all correct!
The unlicensed assistive personnel (UAP) is bathing the client diagnosed with acute respiratory
distress syndrome (ARDS). The bed is in a high position with the opposite side rail in the low position.
Which action should the nurse implement?
1. Demonstrate the correct technique for giving a bed bath.
2. Encourage the UAP to put the bed in the lowest position.
3. Instruct the UAP to get another person to help with the bath.
4. Provide praise for performing the bath safely for the client and the UAP.
1. The opposite side rail should be elevated so the client will not fall out of the bed. Safety is priority, the
nurse should demonstrate the proper way to bathe a client in the bed.
The client diagnosed with ARDS is transferred to the intensive care department and placed on a
ventilator. Which intervention should the nurse implement first?
1. Confirm that the ventilator settings are correct.
2. Verify that the ventilator alarms are functioning properly.
3. Assess the respiratory status and pulse oximeter reading.
4. Monitor the client's arterial blood gas results.
3. Assessment is the first part of the nursing process and is the first intervention the nurse should
implement when caring for a client on a ventilator.
The nurse suspects the client may be developing ARDS. Which assessment data confirm the diagnosis
of ARDS?
1. Low arterial oxygen when administering high concentration of oxygen.
2. The client has dyspnea and tachycardia and is feeling anxious.
3. Bilateral breath sounds clear and pulse oximeter reading is 95%.
4. The client has jugular vein distention and frothy sputum.
1. The classic sign of ARDS is decreased arterial oxygen level (PaO2) while administering high levels of
oxygen; the oxygen is unable to cross the alveolar membrane.
The client who smokes two (2) packs of cigarettes a day develops ARDS after a near-drowning. The
client asks the nurse, "What is happening to me? Why did I get this?" Which statement by the nurse is
most appropriate?
1. "Most people who almost drown end up developing ARDS."
2. "Platelets and fluid enter the alveoli due to permeability instability."
, 3. "Your lungs are filling up with fluid, causing breathing problems."
4. "Smoking has caused your lungs to become weakened, so you got ARDS."
3. This is a basic layperson's terms explanation of ARDS and explains why the client is having trouble
breathing.
Which assessment data indicate to the nurse the client diagnosed with ARDS has experienced a
complication secondary to the ventilator?
1. The client's urine output is 100 mL in four (4) hours.
2. The pulse oximeter reading is greater than 95%.
3. The client has asymmetrical chest expansion.
4. The telemetry reading shows sinus tachycardia.
3. Asymmetrical chest expansion indicates the client has had a pneumothorax, which is a complication of
mechanical ventilation
The health-care provider ordered STAT arterial blood gases (ABGs) for the client diagnosed with ARDS.
The ABG results are pH 7.38, PaO2 92, Pa CO238, HCO324. Which action should the nurse implement?
1. Continue to monitor the client without taking any action.
2. Encourage the client to take deep breaths and cough.
3. Administer one (1) ampule of sodium bicarbonate IVP.
4. Notify the respiratory therapist of the ABG results.
1. These arterial blood gases are within normal limits, and therefore the nurse should not take any
action except to continue to monitor the client.
The client with ARDS is on a mechanical ventilator. Which intervention should be included in the
nursing care plan addressing the endotracheal tube care?
1. Do not move or touch the ET tube.
2. Obtain a chest x-ray daily.
3. Determine if the ET cuff is deflated.
4. Ensure that the ET tube is secure.
4. The ET tube should be secure to ensure it does not enter the right main bronchus. The ET tube should
be one (1) inch above the bifurcation of the bronchi
Which medication should the nurse anticipate the health-care provider ordering for the client
diagnosed with ARDS?
1. An aminoglycoside antibiotic.
2. A synthetic surfactant.
3. A potassium cation.
4. A nonsteroidal anti-inflammatory drug.
2. Surfactant therapy may be prescribed to reduce the surface tension in the alveoli. The surfactant
helps maintain open alveoli, decreases the work of breathing, improves compliance, and helps prevent
atelectasis
The client diagnosed with ARDS is in respiratory distress and the ventilator is malfunctioning. Which
intervention should the nurse implement first?
100% all correct!
The unlicensed assistive personnel (UAP) is bathing the client diagnosed with acute respiratory
distress syndrome (ARDS). The bed is in a high position with the opposite side rail in the low position.
Which action should the nurse implement?
1. Demonstrate the correct technique for giving a bed bath.
2. Encourage the UAP to put the bed in the lowest position.
3. Instruct the UAP to get another person to help with the bath.
4. Provide praise for performing the bath safely for the client and the UAP.
1. The opposite side rail should be elevated so the client will not fall out of the bed. Safety is priority, the
nurse should demonstrate the proper way to bathe a client in the bed.
The client diagnosed with ARDS is transferred to the intensive care department and placed on a
ventilator. Which intervention should the nurse implement first?
1. Confirm that the ventilator settings are correct.
2. Verify that the ventilator alarms are functioning properly.
3. Assess the respiratory status and pulse oximeter reading.
4. Monitor the client's arterial blood gas results.
3. Assessment is the first part of the nursing process and is the first intervention the nurse should
implement when caring for a client on a ventilator.
The nurse suspects the client may be developing ARDS. Which assessment data confirm the diagnosis
of ARDS?
1. Low arterial oxygen when administering high concentration of oxygen.
2. The client has dyspnea and tachycardia and is feeling anxious.
3. Bilateral breath sounds clear and pulse oximeter reading is 95%.
4. The client has jugular vein distention and frothy sputum.
1. The classic sign of ARDS is decreased arterial oxygen level (PaO2) while administering high levels of
oxygen; the oxygen is unable to cross the alveolar membrane.
The client who smokes two (2) packs of cigarettes a day develops ARDS after a near-drowning. The
client asks the nurse, "What is happening to me? Why did I get this?" Which statement by the nurse is
most appropriate?
1. "Most people who almost drown end up developing ARDS."
2. "Platelets and fluid enter the alveoli due to permeability instability."
, 3. "Your lungs are filling up with fluid, causing breathing problems."
4. "Smoking has caused your lungs to become weakened, so you got ARDS."
3. This is a basic layperson's terms explanation of ARDS and explains why the client is having trouble
breathing.
Which assessment data indicate to the nurse the client diagnosed with ARDS has experienced a
complication secondary to the ventilator?
1. The client's urine output is 100 mL in four (4) hours.
2. The pulse oximeter reading is greater than 95%.
3. The client has asymmetrical chest expansion.
4. The telemetry reading shows sinus tachycardia.
3. Asymmetrical chest expansion indicates the client has had a pneumothorax, which is a complication of
mechanical ventilation
The health-care provider ordered STAT arterial blood gases (ABGs) for the client diagnosed with ARDS.
The ABG results are pH 7.38, PaO2 92, Pa CO238, HCO324. Which action should the nurse implement?
1. Continue to monitor the client without taking any action.
2. Encourage the client to take deep breaths and cough.
3. Administer one (1) ampule of sodium bicarbonate IVP.
4. Notify the respiratory therapist of the ABG results.
1. These arterial blood gases are within normal limits, and therefore the nurse should not take any
action except to continue to monitor the client.
The client with ARDS is on a mechanical ventilator. Which intervention should be included in the
nursing care plan addressing the endotracheal tube care?
1. Do not move or touch the ET tube.
2. Obtain a chest x-ray daily.
3. Determine if the ET cuff is deflated.
4. Ensure that the ET tube is secure.
4. The ET tube should be secure to ensure it does not enter the right main bronchus. The ET tube should
be one (1) inch above the bifurcation of the bronchi
Which medication should the nurse anticipate the health-care provider ordering for the client
diagnosed with ARDS?
1. An aminoglycoside antibiotic.
2. A synthetic surfactant.
3. A potassium cation.
4. A nonsteroidal anti-inflammatory drug.
2. Surfactant therapy may be prescribed to reduce the surface tension in the alveoli. The surfactant
helps maintain open alveoli, decreases the work of breathing, improves compliance, and helps prevent
atelectasis
The client diagnosed with ARDS is in respiratory distress and the ventilator is malfunctioning. Which
intervention should the nurse implement first?
