A client is admitted to the intensive care unit (ICU) with sepsis and acute respiratory distress syndrome (ARDS). The client is orally intubated and mechanically ventilated. Which intervention is most important for the nurse to include in the client's plan of care (POC)?

Teach communication board use.

Use antiseptic solution with oral care.

Recommend hours for visitation.

Promote uninterrupted periods of sleep.

Answer and Explanation

The Correct Answer is B

A. Teach communication board use. While nonverbal communication tools are helpful for intubated clients, they do not directly prevent complications associated with mechanical ventilation and ARDS. The priority in this critically ill client is to prevent ventilator-associated pneumonia (VAP) and sepsis-related complications.
B. Use antiseptic solution with oral care. Clients on mechanical ventilation are at high risk for ventilator-associated pneumonia (VAP), which worsens outcomes in ARDS. Using an antiseptic solution (such as chlorhexidine) for oral care reduces bacterial colonization in the oropharynx, decreasing the risk of VAP. This intervention is a key component of ventilator bundle protocols to improve survival rates in critically ill patients.
C. Recommend hours for visitation. While family support is important, setting visitation hours does not directly impact the client's recovery from ARDS and sepsis. Infection prevention and lung protection strategies take higher priority in the acute phase.
D. Promote uninterrupted periods of sleep. Rest is important for critically ill clients, but preventing life-threatening complications such as VAP, sepsis progression, and oxygenation failure takes precedence. Proper oral care with antiseptics directly reduces infection risk and improves patient outcomes.

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Correct Answer is ["C","E","F"]

Explanation

A. White blood cell differential. Although infection is a common precipitating factor for DKA, an elevated WBC count is common in DKA due to stress, dehydration, and inflammation rather than infection itself. While a WBC differential may be done if infection is suspected, it is not a primary test for DKA management.
B. Hemoglobin A1C. Hemoglobin A1C (HbA1c) reflects long-term glucose control (past 2-3 months) but does not provide immediate information about the current metabolic status or severity of DKA. While it may be useful in assessing overall diabetes management, it is not essential for acute DKA treatment.
C. Serum electrolytes. Patients with DKA experience significant electrolyte imbalances, particularly potassium depletion due to osmotic diuresis and insulin deficiency. Monitoring serum sodium, potassium, and bicarbonate is crucial for guiding fluid and electrolyte replacement therapy. Potassium levels may appear normal or high initially due to acidosis but typically drop with insulin administration.
D. Urine culture. A urine culture is only indicated if a urinary tract infection (UTI) is suspected as a trigger for DKA. However, routine urine culture is not required in every case of DKA unless there are symptoms of infection such as fever, dysuria, or pyuria.
E. Anion gap. DKA is a form of high anion gap metabolic acidosis, caused by the accumulation of ketones. The anion gap (AG) is calculated as (Na⁺ - [Cl⁻ + HCO₃⁻]), with a value >12 mEq/L indicating metabolic acidosis. Monitoring the anion gap helps assess the severity of acidosis and guide treatment progress, as a decreasing anion gap suggests resolution of ketosis.
F. Urine ketones. Urine ketone testing helps confirm the presence of ketoacidosis, particularly in the initial stages of DKA diagnosis. While serum beta-hydroxybutyrate is a more accurate indicator of ketone levels, urine ketones remain useful for initial screening and monitoring treatment response as they decrease with appropriate management.

Correct Answer is ["5"]

Explanation

Calculation:

Calculate the New Nitroglycerin Dose in mcg/hour

Dose (mcg/hour) = Dose (mcg/min) × 60 min/hour

=15 mcg/min × 60 min/hour = 900 mcg/hour

Convert mcg to mg

Dose (mg/hour) = Dose (mcg/hour) / 1000 mcg/mg

=900 mcg/hour / 1000 mcg/mg

= 0.9 mg/hour

Calculate the Concentration of Nitroglycerin in the IV Bag

Concentration (mg/mL) = Total mg of Nitroglycerin / Total mL of Solution

=50 mg / 250 mL

= 0.2 mg/mL

Calculate the Infusion Rate = Infusion Rate (mL/hour)

=0.9 mg/hour / 0.2 mg/mL

= 4.5 mL/hour

Round to the Nearest Whole Number

4.5 mL/hour rounded to 5 mL/hour

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A client is admitted to the intensive care unit (ICU) with sepsis and acute respiratory distress syndrome (ARDS). The client is orally intubated and mechanically ventilated. Which intervention is most important for the nurse to include in the client's plan of care (POC)?

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Naxlex Comprehensive Predictor Exams

Exhibits Which other labs would be helpful for the treatment of diabetic ketoacidosis (DKA)? Select all that apply.

Correct Answer is ["C","E","F"]

Explanation

Correct Answer is ["5"]

Explanation

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