A client was successfully extubated after several days of sedation and mechanical ventilation and is currently receiving 40% oxygen via a face mask. While making rounds, the nurse finds the client confused and attempting to get out of bed. Current vital signs are an oral temperature 99.2°F (37.3° C), heart rate 112 beats/minutes, respirations 16 breaths/minute, blood pressure 100/70 mm Hg, and an oxygen saturation of 98%. Which intervention should the nurse implement?
Administer a PRN dose of benzodiazepine.
Increase the oxygen concentration to 60%.
Apply bilateral wrist restraints.
Notify the rapid response team.
The Correct Answer is C
A. Administer a PRN dose of benzodiazepine.
Benzodiazepines can cause respiratory depression and prolong delirium, especially in clients recovering from mechanical ventilation and sedation. The client’s confusion is likely transient post-extubation delirium, which often resolves with reorientation and safety measures rather than sedation.
B. Increase the oxygen concentration to 60%.
The client is maintaining an oxygen saturation of 98% on 40% FiO₂, indicating adequate oxygenation. Increasing the oxygen concentration to 60% is unnecessary and may increase the risk of oxygen toxicity.
C. Apply bilateral wrist restraints.
The client is confused and attempting to get out of bed, increasing the risk of falls and accidental self-injury. Restraints should be used as a last resort after ensuring non-pharmacological interventions (e.g., reorientation, sitter, bed alarms) are ineffective or unavailable. If applied, restraints must be monitored closely and removed as soon as possible.
D. Notify the rapid response team.
The client’s vital signs are stable, and oxygenation is adequate. Although confusion is concerning, it does not indicate an immediate life-threatening emergency requiring a rapid response team. Instead, the nurse should implement safety interventions and continue close monitoring.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
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).
Correct Answer is B
Explanation
A. View the rhythm in another chest lead. While verifying the rhythm in another lead may help confirm the accuracy of the monitor, it does not address the immediate absence of a pulse and respirations. The client is in pulseless electrical activity (PEA), which requires immediate intervention rather than rhythm verification.
B. Begin chest compressions at a rate of 120 times a minute. The client has no palpable carotid pulse and no spontaneous respirations despite a sinus rhythm on the monitor, indicating pulseless electrical activity (PEA). PEA is a form of cardiac arrest where the heart shows electrical activity but fails to generate effective circulation. Immediate high-quality chest compressions are essential to maintain perfusion while addressing the underlying cause, such as hypovolemia or tension pneumothorax.
C. Auscultate all chest fields for muffled lung sounds. While assessing for muffled lung sounds may help detect conditions such as tension pneumothorax or hemothorax, it should not delay the initiation of CPR. Once compressions are started, the underlying cause of PEA can be investigated.
D. Observe for swelling at the fracture site. Swelling at the fracture site may indicate bleeding or compartment syndrome, but assessing the fracture should not take priority over initiating CPR. If hemorrhage is suspected as a cause of PEA, rapid fluid resuscitation should be initiated after starting chest compressions.
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