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 A

Explanation

Choice A reason:

Administering Nitroglycerin 0.4 mg sublingually STAT for the client experiencing chest pain should be the nurse's priority because chest pain can be indicative of a myocardial infarction (heart attack), which is a medical emergency. Quick administration of Nitroglycerin can help to relieve chest pain, improve blood flow to the heart, and prevent further cardiac damage.

Choice B reason:

While administering Lorazepam 2 mg IV for the client experiencing restlessness and picking at tubing is important for patient safety and comfort, it is not as urgent as addressing potential cardiac issues indicated by chest pain.

Choice C reason:

Administering Morphine sulfate 4 mg IV for incisional pain management is necessary for the patient’s comfort and pain control but is not as critical as treating potential life-threatening chest pain.

Choice D reason:

Administering one unit of packed red blood cells STAT for the client with a hemoglobin of 9.5 g/dL is important but does not take precedence over the immediate risk of a myocardial infarction. The hemoglobin level, while low, is not immediately life-threatening compared to the chest pain scenario.

A. Provide small doses of opioid analgesia B. Maintain pCO2 of 35-45 C. Administer an anti-anxiety agent D. Monitor blood pressure every four hours

Correct Answer is B

Explanation

Choice A reason:

Providing small doses of opioid analgesia is important for pain management, but it is not the highest priority in a patient with a closed head injury on mechanical ventilation. Pain control should be balanced with the need to monitor neurological status.

Choice B reason:

Maintaining pCO2 of 35-45 is critical for patients with a closed head injury on mechanical ventilation. Proper pCO2 levels help manage intracranial pressure (ICP) and prevent secondary brain injury. Hyperventilation to lower pCO2 can reduce ICP but must be carefully controlled to avoid cerebral ischemia.

Choice C reason:

Administering an anti-anxiety agent can help manage agitation and anxiety, but it is not the highest priority. Sedation must be used cautiously in head injury patients to avoid masking changes in neurological status.

Choice D reason:

Monitoring blood pressure every four hours is necessary for overall patient care, but continuous monitoring and immediate interventions are more critical in managing intracranial pressure and preventing secondary brain injury.

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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

The nurse receives new orders for multiple clients. Which order should be the nurse's priority?

Correct Answer is A

Explanation

A nurse is caring for a patient with a closed head injury on mechanical ventilation. Which of the following actions is highest priority?

Correct Answer is B

Explanation

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