Question

The nurse is caring for a client with Acute Respiratory Distress Syndrome (ARDS) who has developed atelectasis. Which collaborative intervention would the nurse anticipate the health care provider to prescribe to best assist in opening the client's collapsed alveoli?

Answer 1

Correct Answers:

Positive End Expiratory Pressure (PEEP)

Rationale :

🔴 PEEP prevents alveolar collapse by maintaining positive pressure in the lungs at the end of expiration.

🔴 It improves oxygenation by increasing the functional residual capacity.

🔴 Helps recruit collapsed alveoli, especially critical in ARDS patients.

🔴 Reduces intrapulmonary shunting and enhances ventilation-perfusion (V/Q) matching.

🔴 Allows for a lower FiO₂ while maintaining adequate oxygenation, reducing oxygen toxicity.

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Answer 2

Correct Answers:

Follow facility policy or the drug literature (drug manufacturer) directions.

Rationale :

🟣 Drug compatibility depends on concentration, diluent, and infusion timing, which can vary by drug.

🟣 Facility policy and drug guides offer up-to-date, evidence-based compatibility data.

🟣 Prevents potential precipitation, inactivation, or toxicity when drugs are combined.

🟣 Consulting literature reduces risk of medication errors and adverse events.

🟣 It ensures safe, standardized practice consistent with organizational protocols.

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Answer 3

Correct Answers:

Abrupt discontinuation of high doses may cause severe withdrawal symptoms.

Rationale :

🟡 High-dose benzodiazepines can lead to physiological dependence, even over short periods.

🟡 Abrupt cessation may cause seizures, agitation, insomnia, and hallucinations.

🟡 Tapering allows the brain to recalibrate GABA receptor activity slowly.

🟡 Nurse should inform patient about the need for gradual dose reduction.

🟡 Monitoring during withdrawal is vital to avoid rebound symptoms.

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Answer 4

Correct Answers:

Use simple words and instructions to communicate with the client.

Rationale :

🔵 Clients with disorganized speech may have impaired attention and thought processing.

🔵 Using simple, short phrases promotes understanding and minimizes confusion.

🔵 Avoids misinterpretation or increased anxiety that complex instructions may cause.

🔵 Builds rapport and therapeutic alliance, encouraging client participation.

🔵 Supports clear, effective communication, especially during acute psychotic episodes.

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Answer 5

Correct Answers:

Attach the pulse oximeter.

Rationale :

🟢 Pulse oximetry provides rapid, noninvasive assessment of oxygen saturation.

🟢 Determines the degree of hypoxia, guiding urgency of interventions.

🟢 Quick initial step before escalating care (e.g., oxygen or ABGs).

🟢 Confusion and cyanosis are signs of impaired cerebral and peripheral oxygenation.

🟢 Establishing a baseline SpO₂ is critical to monitor therapy effectiveness.

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Answer 6

Correct Answers:

The patient may have developed a pneumothorax.

Rationale :

🔶 Air can enter the pleural space during thoracentesis, causing lung collapse.

🔶 Tachypnea, dyspnea, and decreased breath sounds are classic signs.

🔶 Pneumothorax is a life-threatening emergency requiring prompt intervention.

🔶 Post-procedure monitoring includes chest auscultation and follow-up imaging.

🔶 Nurses should immediately report worsening respiratory symptoms after the procedure.

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Answer 7

Correct Answers:

Approach the client and ask if they are experiencing hallucinations arid assess the content of the hallucinations

Rationale :

🟤 Directly engaging helps determine if the hallucinations are command-type or harmful.

🟤 Shows empathy and interest, encouraging trust and therapeutic connection.

🟤 Assessment helps determine severity, frequency, and associated behaviors.

🟤 Important to maintain safety for client and others if hallucinations are dangerous.

🟤 Guides further intervention, such as medication adjustment or psych consult.

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Answer 8

Correct Answers:

The client who has been deemed incompetent by the court.

Rationale :

🔴 Clients deemed incompetent by a court require a court-appointed legal guardian.

🔴 If client is not competent, consent must be obtained from legally authorized surrogate.

🔴 Consent from the client is invalid if competency is compromised.

🔴 Nurses must ensure consent is legally and ethically valid before procedure.

🔴 Documentation must reflect who signed and under what authority.

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Answer 9

Correct Answers:

Receiving lorazepam 2mg intravenous push (IVP).

Rationale :

🟣 Lorazepam is a CNS depressant, and IV administration causes rapid onset of sedation.

🟣 IV push increases the risk of hypoventilation and decreased LOC.

🟣 Higher doses or rapid administration in older adults intensify respiratory depression.

🟣 Close respiratory rate and O₂ sat monitoring required.

🟣 Nurses must ensure emergency airway equipment is readily available.

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Answer 10

Correct Answers:

Auscultate breath sounds bilaterally.

Rationale :

🟡 Comparing lung sounds bilaterally helps detect early signs of pneumothorax or hemothorax.

🟡 Decreased or absent sounds may indicate lung collapse, bleeding, or obstruction.

🟡 This assessment directs urgency of intervention (e.g., chest tube or imaging).

🟡 Should precede other interventions such as oxygen or labs.

🟡 Accurate auscultation can guide triage and emergency management.

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Custom: NUR 202 Test 1B Spring~2025

No.

1 :
The nurse is caring for a client with Acute Respiratory Distress Syndrome (ARDS) who has developed atelectasis. Which collaborative intervention would the nurse anticipate the health care provider to prescribe to best assist in opening the client's collapsed alveoli?

2 :
A client is receiving an intravenous push (IVP) medication. If this type of medication infiltrates into the outer tissues of the forearm during the IVP, what is the FIRST response of the nurse?

3 :
A client is prescribed lorazepam. What does the nurse know to be TRUE regarding this medication?

4 :
A client diagnosed with Post-Traumatic Stress Disorder (PTSD) is in their room experiencing a flashback. The client is re-living auditory and visual elements of the traumatic event. Which nursing intervention is MOST appropriate?

8 :
A nurse in orientation on the mental health unit is instructed that certain criteria must be met prior to administering medication to a client without their consent. Which client CANNOT refuse their medication?

9 :
A client diagnosed with Acute Respiratory Distress Syndrome (ARDS) has an endotracheal tube (ETT) attached to a mechanical ventilator and is about to begin the weaning process. The nurse determines which measure may interfere with the weaning process?

10 :
The nurse is providing care for a client with an endotracheal tube (ETT). What is the BEST method to evaluate the proper placement of an endotracheal tube?

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Custom: NUR 202 Test 1B Spring~2025

No.

1 : The nurse is caring for a client with Acute Respiratory Distress Syndrome (ARDS) who has developed atelectasis. Which collaborative intervention would the nurse anticipate the health care provider to prescribe to best assist in opening the client's collapsed alveoli?

2 : A client is receiving an intravenous push (IVP) medication. If this type of medication infiltrates into the outer tissues of the forearm during the IVP, what is the FIRST response of the nurse?

3 : A client is prescribed lorazepam. What does the nurse know to be TRUE regarding this medication?

4 : A client diagnosed with Post-Traumatic Stress Disorder (PTSD) is in their room experiencing a flashback. The client is re-living auditory and visual elements of the traumatic event. Which nursing intervention is MOST appropriate?

8 : A nurse in orientation on the mental health unit is instructed that certain criteria must be met prior to administering medication to a client without their consent. Which client CANNOT refuse their medication?

9 : A client diagnosed with Acute Respiratory Distress Syndrome (ARDS) has an endotracheal tube (ETT) attached to a mechanical ventilator and is about to begin the weaning process. The nurse determines which measure may interfere with the weaning process?

10 : The nurse is providing care for a client with an endotracheal tube (ETT). What is the BEST method to evaluate the proper placement of an endotracheal tube?

1 :
The nurse is caring for a client with Acute Respiratory Distress Syndrome (ARDS) who has developed atelectasis. Which collaborative intervention would the nurse anticipate the health care provider to prescribe to best assist in opening the client's collapsed alveoli?

2 :
A client is receiving an intravenous push (IVP) medication. If this type of medication infiltrates into the outer tissues of the forearm during the IVP, what is the FIRST response of the nurse?

3 :
A client is prescribed lorazepam. What does the nurse know to be TRUE regarding this medication?

4 :
A client diagnosed with Post-Traumatic Stress Disorder (PTSD) is in their room experiencing a flashback. The client is re-living auditory and visual elements of the traumatic event. Which nursing intervention is MOST appropriate?

8 :
A nurse in orientation on the mental health unit is instructed that certain criteria must be met prior to administering medication to a client without their consent. Which client CANNOT refuse their medication?

9 :
A client diagnosed with Acute Respiratory Distress Syndrome (ARDS) has an endotracheal tube (ETT) attached to a mechanical ventilator and is about to begin the weaning process. The nurse determines which measure may interfere with the weaning process?

10 :
The nurse is providing care for a client with an endotracheal tube (ETT). What is the BEST method to evaluate the proper placement of an endotracheal tube?