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 observes a colleague ignoring proper hand hygiene protocols. What should the nurse do first?

Correct answer: D

Rationale: The correct first action for the nurse to take in this situation is to file an incident report immediately. By doing so, the nurse ensures that the unsafe practice is documented for further investigation and corrective action. Speaking to the colleague directly may not address the root cause of the issue and could lead to potential conflicts. Ignoring the situation is not an appropriate response as it compromises patient safety. Reporting the colleague to the nursing manager should be done after filing an incident report to ensure that appropriate actions are taken to prevent future occurrences of non-compliance with hand hygiene protocols.

3. A nurse is preparing to administer aspirin 650mg PO every 12 hr. The amount available is aspirin 325mg tablets. How many tablets should the nurse administer?

Correct answer: B

Rationale: The correct answer is 2 tablets. Each tablet of aspirin is 325mg. To achieve the required dose of 650mg, the nurse should administer 2 tablets. Choice A (1 tablet) is incorrect because it would only provide 325mg, which is half the required dose. Choices C (3 tablets) and D (4 tablets) are incorrect as they would exceed the required dose.

4. A client undergoing surgery refuses to remove religious jewelry. What is the best course of action?

Correct answer: B

Rationale: The correct course of action is to remove the jewelry and document the removal. While religious beliefs should be respected, ensuring patient safety during surgery is crucial. Securing the jewelry may not be sufficient to prevent any interference during the surgical procedure. Documenting the removal is important for legal and documentation purposes. Delaying the surgery or removing the jewelry with the family's permission may not be the best options as patient safety should be the top priority in this situation.

5. A nurse suspects a colleague of diverting narcotics. What is the nurse's first course of action?

Correct answer: B

Rationale: The correct first course of action for a nurse suspecting a colleague of diverting narcotics is to report the suspicion to the nurse manager. Confronting the colleague directly may not be safe and could compromise the investigation. Ignoring the situation is not appropriate as it can pose risks to patient safety. Keeping a record of the colleague's actions is not the primary action to take when drug diversion is suspected; reporting to the nurse manager is crucial for proper investigation and ensuring patient safety.

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