A client is on mechanical ventilation and the client's spouse wonders why famotidine is needed since the client "only has lung problems." What response by the nurse is best?

It will prepare the gastrointestinal tract for enteral feedings.

It will increase the motility of the gastrointestinal tract.

It will keep the gastrointestinal tract functioning normally.

It will prevent ulcers from the stress of mechanical ventilation.

Answer and Explanation

The Correct Answer is D

Choice A reason:

While preparing the gastrointestinal tract for enteral feedings is important, it is not the primary reason for administering famotidine. Famotidine is typically used to reduce gastric acid production, not to prepare the GI tract for feedings.

Choice B reason:

Increasing the motility of the gastrointestinal tract is not the primary function of famotidine. Famotidine is an H2 receptor antagonist that works by decreasing the production of stomach acid.

Choice C reason:

Keeping the gastrointestinal tract functioning normally is a broad statement and does not specifically address the reason for administering famotidine. The drug's role in preventing stress ulcers is more relevant to the patient's current condition.

Choice D reason:

Famotidine is used to prevent stress ulcers, which can occur in critically ill patients, including those on mechanical ventilation. The stress of illness and mechanical ventilation increases the risk of developing gastric ulcers, and famotidine helps reduce this risk by decreasing gastric acid secretion.

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Correct Answer is D

Explanation

Choice A reason:

Decorticate posturing involves abnormal flexion of the arms towards the chest and extension of the legs. This posture indicates damage to the corticospinal tract at the level of the diencephalon. The described response does not match decorticate posturing.

Choice B reason:

Flexion withdrawal is a response to painful stimuli where the patient pulls away or flexes the affected limb. This is a less severe response than posturing and does not match the description provided in the scenario.

Choice C reason:

Localization of pain refers to the patient's ability to purposefully move a hand to the site of a painful stimulus, indicating higher brain function. The described response of arm and leg extension with pronation does not fit this description.

Choice D reason:

Decerebrate posturing is characterized by extension of the arms and legs, pronation of the arms, and plantar flexion. This posture indicates severe brainstem damage and is consistent with the described response.

A. Encourage patient to deep breathe and use incentive spirometer B. Offer the patient medication for sedation C. Assess patient's ability to speak D. Assess vital signs and effort of breathing

Correct Answer is D

Explanation

Choice A reason:

Encouraging the patient to deep breathe and use an incentive spirometer is important for lung expansion and preventing atelectasis. However, it is not the most immediate action following extubation.

Choice B reason:

Offering the patient medication for sedation is not appropriate immediately following extubation, as it could depress respiratory function and interfere with the patient's ability to clear secretions and maintain an open airway.

Choice C reason:

Assessing the patient's ability to speak is important to ensure that the vocal cords were not damaged during the intubation process. However, this is secondary to ensuring that the patient is breathing effectively and maintaining adequate oxygenation.

Choice D reason:

Assessing vital signs and effort of breathing is the most immediate and important action following extubation. Monitoring the patient’s respiratory status ensures that they are maintaining a patent airway, breathing effectively, and not experiencing respiratory distress or failure.

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A client is on mechanical ventilation and the client's spouse wonders why famotidine is needed since the client "only has lung problems." What response by the nurse is best?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse applies a painful stimulus to the nailbeds of an unconscious patient. The patient responds with extension of the arms and legs, pronation of the arms, and plantar flexion. The nurse documents this as:

Correct Answer is D

Explanation

Which would be the most important action immediately following extubation of a patient?

Correct Answer is D

Explanation

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