A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate?

Assess the cause of the agitation.

Reassure the client that he or she is safe.

Restrain the client's hands.

Sedate the client immediately.

Answer and Explanation

The Correct Answer is A

A. Assess the cause of the agitation: This is the most appropriate action. Agitation in a mechanically ventilated patient can be due to multiple causes, such as pain, hypoxia, or discomfort. It is crucial to assess and identify the underlying cause to address it appropriately.

B. Reassure the client that he or she is safe: While reassurance is important, it may not address the root cause of the agitation, especially if it is related to a physical issue such as hypoxia or tube displacement.

C. Restrain the client's hands: Restraining should be a last resort after other interventions have failed. Restraints can cause further agitation and distress.

D. Sedate the client immediately: Sedating the client without assessing the cause of the agitation could mask serious issues and lead to inappropriate treatment.

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Correct Answer is C

Explanation

A. Partially compensated Metabolic Alkalosis: This is incorrect because the pH is within normal limits (7.35-7.45), and the elevated PaCO2 and bicarbonate suggest a respiratory issue rather than a metabolic one.

B. Fully compensated Metabolic Acidosis: This is incorrect because the primary disturbance is respiratory, not metabolic. A compensated metabolic acidosis would typically show a low PaCO2 as compensation.

C. Fully compensated Respiratory Acidosis: Correct. The pH is within the normal range, indicating full compensation. The elevated PaCO2 and bicarbonate reflect a chronic respiratory acidosis that has been compensated by the kidneys.

D. Partially compensated Respiratory Alkalosis: This is incorrect because in respiratory alkalosis, the PaCO2 would be low, not high.

A. dark coloured urine B. dark coloured stool C. jaundice D. pruritis E. ascites

Correct Answer is B

Explanation

A. Dark colored urine: Dark urine can be a sign of bilirubin buildup in the body due to liver dysfunction, commonly seen in cirrhosis.

B. Dark colored stool: This is not typically associated with cirrhosis. Dark stools can indicate gastrointestinal bleeding, but in cirrhosis, stools are more likely to be pale or clay-colored due to a lack of bile.

C. Jaundice: Jaundice occurs due to the liver's inability to process bilirubin, leading to yellowing of the skin and eyes.

D. Pruritus: Pruritus, or itching, is common in cirrhosis due to bile salt deposition in the skin.

E. Ascites: Ascites, the accumulation of fluid in the abdomen, is a common complication of cirrhosis due to portal hypertension and low albumin levels.

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A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate?

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