A 44-year-old female patient has been admitted for an abdominal abscess and sepsis.
She has been on mechanical ventilatory support for the last 2 weeks and is due to start ventilator weaning today.
She is currently on pressure support of 25 cm water (H2O) with no mandatory breaths and a fraction of inspired oxygen (FiO2) of 35%. What should the nurse do next?

Set up supplemental oxygen delivery.

Increase the fraction of inspired oxygen.

Gather supplies for extubation.

Place a nasogastric tube.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Setting up supplemental oxygen delivery is not the immediate action the nurse should take. The patient’s FiO2 is currently at 35%, which is within the normal range.

Choice B rationale

Increasing the fraction of inspired oxygen is not necessary at this time. The patient’s current FiO2 is within the normal range.

Choice C rationale

The nurse should gather supplies for extubation. As the patient is due to start ventilator weaning, preparing for extubation is the next logical step. This involves having all necessary equipment and personnel ready for the procedure.

Choice D rationale

Placing a nasogastric tube is not the immediate action the nurse should take. While a nasogastric tube can be used to provide nutrition and medication, it is not directly related to the process of ventilator weaning.

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Correct Answer is B

Explanation

Choice A rationale

Encouraging the client to drink at least 3 to 4 liters of water prior to the procedure is not a standard preparation for an intravenous pyelogram (IVP). Overhydration could potentially complicate the procedure.

Choice B rationale

It is essential for the nurse to notify the healthcare provider if the client reports any allergies to iodine or shellfish. The contrast dye used in an IVP often contains iodine. People who are allergic to iodine or shellfish may have a reaction to this dye.

Choice C rationale

Instructing the client to keep the legs straight for 6 to 8 hours after the procedure is not a standard instruction for IVP. This instruction is more commonly associated with procedures involving the insertion of a catheter into a large artery or vein.

Choice D rationale

Inserting an indwelling urinary catheter prior to going to the X-ray department is not a standard preparation for an IVP. The procedure involves the injection of a contrast dye into a vein, not the bladder.

A. Limit activity for a day or two after returning home. B. Anticipate a stinging feeling during needle insertion. C. Prepare to sit forward with arms propped on a table. D. Expect a persistent cough after the procedure.

Correct Answer is D

Explanation

Choice A rationale

Limiting activity for a day or two after returning home is a correct understanding. After a thoracentesis, it’s recommended to limit activity for a day or two to allow the body to recover.

Choice B rationale

Anticipating a stinging feeling during needle insertion is a correct understanding. The patient will feel a stinging sensation when the local anesthetic is injected.

Choice C rationale

Preparing to sit forward with arms propped on a table is a correct understanding. This position helps to expand the space between the ribs, making it easier for the doctor to access the pleural space.

Choice D rationale

Expecting a persistent cough after the procedure indicates a need for additional education. While a mild cough immediately after the procedure is normal, a persistent cough could indicate a complication such as a pneumothorax.

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Naxlex Comprehensive Predictor Exams

When preparing a client for an intravenous pyelogram (IVP), it is essential for the nurse to take which action?

Correct Answer is B

Explanation

The nurse is preparing a client for an outpatient thoracentesis.Which statement made by the client indicates a need for additional education?

Correct Answer is D

Explanation

The same 68-year-old male patient from the previous as been assessed. For each of the following findings, indicate whether they are generally associated with a rotator cuff injury or a humeral fracture.

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound.Which action should the nurse take next?

A nurse is providing dietary advice to a patient with hypertension.Which food item would be the best choice for the patient’s lunch?

The nurse is reviewing the nurse’s notes and flow chart to identify trends.Which notations require immediate follow-up?

What nursing interventions are appropriate for a client starting clonazepam? Select all that apply.

The nurse is performing tracheostomy care for a client when a code blue is called for another client on the unit who experiences a cardiopulmonary arrest.Which action should the nurse take?

A client admitted with pneumonia and on bedrest has not had the strength to perform self-care.Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure injury?