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 A

Explanation

A. Normal sinus rhythm (NSR) at 84 beats/minute. The goal of cardioversion for atrial fibrillation (AFib) is to restore a normal sinus rhythm (NSR). NSR indicates that the atria and ventricles are depolarizing in a coordinated manner, reducing the risk of thromboembolism, stroke, and hemodynamic instability. A heart rate of 84 beats/minute is within the normal range, confirming the success of the procedure.
B. Regular rhythm with consistent pacemaker capture. Cardioversion is used to restore normal rhythm in AFib, not to manage pacemaker function. A pacemaker is not part of standard AFib cardioversion unless the client has underlying conduction issues requiring pacing.
C. Return of elevated ST segment to the baseline. ST elevation suggests acute myocardial infarction (MI), which is unrelated to atrial fibrillation or cardioversion. Cardioversion does not treat ST elevation or myocardial ischemia, making this an incorrect indicator of success.
D. Increased frequency of QRS complexes. An increase in QRS frequency suggests tachycardia, which would indicate treatment failure rather than success. The goal of cardioversion is to restore a normal, controlled heart rate and rhythm, not to increase the number of ventricular contractions.

A. Junctional tachycardia. B. Second degree Type II atrioventricular (AV) block (3 to 1). C. Ventricular fibrillation. D. Atrial flutter.

Correct Answer is D

Explanation

A. Junctional tachycardia: Junctional tachycardia originates from the AV node, typically with a narrow QRS, absent or inverted P waves, and a rate of 100–180 bpm. The strip does not show these features.
B. Second-degree Type II AV block (3:1).Type II AV block (Mobitz II) shows dropped QRS complexes with constant PR intervals before conducted beats. This strip does not show missing QRS complexes in a 3:1 pattern.
C. Ventricular fibrillation. VF is characterized by a chaotic, disorganized rhythm with no discernible P waves, QRS complexes, or T waves, completely different from this organized flutter pattern.
D. Atrial flutter is characterized by regular, rapid atrial depolarizations (flutter waves) at a rate of 250–350 bpm. These waves create a "sawtooth" pattern on the ECG.The ventricular response may be regular or irregular, depending on AV conduction. This is different from atrial fibrillation (which has irregularly irregular R-R intervals and no discrete P waves).

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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)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has been treated for uncontrolled atrial fibrillation with cardioversion. Following the cardioversion, which assessment finding indicates to the nurse that the desired outcome was achieved?

Correct Answer is A

Explanation

Based on this rhythm strip, which interpretation should the nurse make?

Correct Answer is D

Explanation

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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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