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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"A"},"E":{"answers":"B"}}

Explanation

Increase the fraction of inspired oxygen (FiO₂). The client has severe COVID pneumonia and is on mechanical ventilation with high inspiratory pressures, suggesting acute respiratory distress syndrome (ARDS). Increasing FiO₂ is indicated if oxygenation is inadequate (e.g., low PaO₂ or SpO₂). However, oxygen toxicity should be avoided, so adjustments should be made based on arterial blood gases (ABGs) and oxygen saturation.
Collect equipment for a needle aspiration. Needle aspiration is typically used for pneumothorax management, but there is no mention of clinical signs such as sudden hypotension, absent breath sounds, or tracheal deviation. While ventilated COVID-19 patients are at risk for barotrauma, this procedure is not justified without evidence of pneumothorax.
Replace the ventilator. There is no indication that the ventilator is malfunctioning or that the settings are inappropriate. If ventilation issues arise (e.g., high plateau pressures, auto-PEEP, or ventilator asynchrony), adjustments to settings, sedation, or lung-protective strategies should be considered before replacing the ventilator.
Measure the nasogastric tube output. The client is intubated and sedated, meaning they cannot protect their airway or tolerate oral intake. A nasogastric (NG) tube is commonly placed for gastric decompression and feeding. Monitoring NG output is essential to assess for gastrointestinal bleeding, ileus, or high residual volumes, which can affect feeding tolerance.
Place the client in Trendelenburg. The Trendelenburg position increases the risk of aspiration, impairs lung expansion, and worsens ventilation-perfusion mismatch, especially in ARDS patients. Instead, prone positioning is often preferred in severe COVID pneumonia to improve oxygenation and alveolar recruitment.

A. Provide a bedside table for client to lean across. B. Place bed in the reverse Trendelenburg position. C. Encourage bed rest until analgesic takes effect. D. Raise the head of the bed to a 90 degree angle.

Correct Answer is A

Explanation

A. Provide a bedside table for the client to lean across. Clients with acute pancreatitis often experience severe epigastric pain that radiates to the back. Leaning forward helps reduce pressure on the inflamed pancreas and relieves pain by minimizing peritoneal irritation. Providing a bedside table allows the client to rest in a comfortable, supported position, improving pain management without additional interventions.
B. Place bed in the reverse Trendelenburg position. Reverse Trendelenburg elevates the head and lowers the feet, which does not specifically relieve pain associated with pancreatitis. The client instinctively leans forward for relief, and adjusting the bed position would not provide the same benefit. This intervention does not directly address the underlying cause of discomfort.
C. Encourage bed rest until analgesic takes effect. Although pain control is essential, keeping the client in a supine or bedrest position can increase abdominal pressure and worsen discomfort. Allowing the client to assume a comfortable position enhances the effectiveness of analgesics and prevents unnecessary distress. Pain relief strategies should focus on both pharmacologic and positioning interventions.
D. Raise the head of the bed to a 90-degree angle. Elevating the head of the bed can improve breathing and reduce reflux, but it does not provide the same pressure relief as leaning forward. Sitting upright without forward support does not effectively relieve peritoneal irritation from pancreatic inflammation. Providing a bedside table supports proper positioning and enhances comfort.

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Naxlex Comprehensive Predictor Exams

Exhibits Click to mark whether the actions are indicated, contraindicated, or nonessential for this client. Each row must have one option selected.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"C"},"D":{"answers":"A"},"E":{"answers":"B"}}

Explanation

A client diagnosed with pancreatitis reports severe epigastric pain. After administering a narcotic analgesic, the client insists on Tip sitting up and leaning forward. Which action should the nurse implement?

Correct Answer is A

Explanation

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