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 patient receiving chemotherapy has developed neutropenia. What should be included in the care plan to reduce infection risk?

Correct answer: D

Rationale: When a patient receiving chemotherapy develops neutropenia, the priority is to reduce the risk of infection. Using reverse isolation precautions is crucial in this situation to protect the patient from exposure to pathogens. Monitoring temperature daily (Choice A) is important but is not as effective as isolating the patient. Limiting visitors (Choice B) can help reduce the risk of exposure, but reverse isolation is a more stringent measure. Administering antibiotics prophylactically (Choice C) is not recommended unless there is a specific indication, as it can contribute to antibiotic resistance.

3. The nurse is caring for a group of medical-surgical patients. A fire has been reported in an adjacent wing of the hospital. What should the nurse do to ensure the patients' safety?

Correct answer: B

Rationale: During a fire emergency, it is crucial to close all doors to contain smoke and fire, helping to protect the patients. This action can prevent the spread of fire and smoke to the area where patients are located. Identifying evacuation routes is also important for a timely and orderly evacuation if necessary. Waiting for the fire department to arrive before taking action (Choice A) can waste valuable time and put patients at risk. Moving bedridden patients in their beds (Choice D) can be dangerous during a fire and should be avoided as it can expose patients and staff to more risks.

4. A nurse manager is teaching a group of staff members about proper body mechanics. Which of the following statements by a staff member indicates an understanding of the teaching?

Correct answer: A

Rationale: Choice A is the correct answer because lifting more than 35 pounds without assistance can cause injury, so getting help is crucial for proper body mechanics. Choice B is incorrect as twisting at the waist can lead to back injuries. Choice C is incorrect as holding objects closer to the body, not 1 ft away, is recommended to reduce strain. Choice D is incorrect as rolling shoulders forward can increase strain on the back instead of reducing it.

5. A healthcare professional is assessing a patient with pneumonia. Which finding is most concerning?

Correct answer: D

Rationale: Crackles heard in the lung bases are most concerning in a patient with pneumonia as they suggest fluid accumulation in the lungs, indicating possible severe infection or respiratory distress. Prompt intervention is required to prevent further complications.\n\nChoice A, fever of 101°F, is common in infections like pneumonia but may not be as immediately concerning as crackles indicating fluid in the lungs.\n\nChoice B, a blood pressure of 140/90 mmHg, is within normal limits and not directly indicative of pneumonia severity.\n\nChoice C, a heart rate of 95 beats per minute, is slightly elevated but not as critical as crackles suggesting fluid in the lungs.

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