A nurse is assisting with weaning a client from the ventilator. Which of the following parts of the ABCDEF assessment tool does the weaning process represent?
Choice of Analgesia and Sedation
Assess, Prevent, and Manage Pain
Delirium: Assess, Prevent, and Manage
Breathing: Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT)
The Correct Answer is D
A. The "Choice of Analgesia and Sedation" component of the ABCDEF assessment tool focuses on selecting appropriate pain relief and sedation strategies for the patient but does not directly relate to the weaning process.
B. "Assess, Prevent, and Manage Pain" involves ensuring the patient is comfortable and free from pain, which is important but not specifically related to weaning from the ventilator.
C. "Delirium: Assess, Prevent, and Manage" addresses the cognitive status of the patient, particularly the prevention and management of delirium, which is a critical aspect of care but not directly related to ventilator weaning.
D. "Breathing: Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT)" directly involves the weaning process, as it includes assessing the patient's ability to breathe independently by reducing or removing sedation (SAT) and evaluating their capacity for spontaneous breathing (SBT).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Report new-onset muscle weakness: Hypokalemia can cause muscle weakness, cramps, and fatigue, which are important symptoms that need to be monitored. Reporting these symptoms promptly is crucial because severe hypokalemia can lead to life-threatening complications, such as respiratory failure or cardiac arrhythmias.
B. Increase consumption of apples and broccoli: While fruits and vegetables like apples and broccoli are healthy, they are not particularly high in potassium. The client should be encouraged to consume potassium-rich foods such as bananas, oranges, potatoes, and spinach to help correct hypokalemia.
C. Avoid salt substitutes: Some salt substitutes contain potassium chloride, which can actually help increase potassium levels. However, this option might be recommended in certain conditions where potassium levels need to be carefully controlled, such as in renal failure, not in hypokalemia management.
D. Report falls, due to high risk of osteoporosis: Hypokalemia does not directly increase the risk of osteoporosis. Falls may occur due to muscle weakness, but this is not specifically related to osteoporosis. Therefore, reporting falls is not the primary concern in hypokalemia.
Correct Answer is B
Explanation
A. Osmoreceptors in the pituitary gland regulate the secretion of cortisol in response to changes in plasma osmolality: This is incorrect as the pituitary gland itself does not have osmoreceptors; rather, the hypothalamus contains osmoreceptors.
B. Osmoreceptors in the hypothalamus detect high plasma osmolality and stimulate the release of antidiuretic hormone (ADH), which enhances water reabsorption in the kidneys: This is correct. Osmoreceptors in the hypothalamus sense changes in plasma osmolality and regulate ADH release to maintain water balance.
C. Osmoreceptors in the kidneys monitor blood pressure changes and regulate aldosterone secretion to control sodium reabsorption and water balance: This is not correct because the kidneys primarily use juxtaglomerular cells to sense blood pressure changes and regulate aldosterone, not osmoreceptors.
D. Osmoreceptors in the hypothalamus detect low plasma osmolality and inhibit the release of antidiuretic hormone (ADH), leading to increased urine production: This is partially correct; osmoreceptors do detect low osmolality, but their inhibition of ADH would decrease urine production, not increase it.
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