A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following findings is the nurse's priority?

Tachycardia

Cramping

Seizures

Elevated temperature

Answer and Explanation

The Correct Answer is C

Explanation: The nurse should prioritize seizures as the most serious and life-threatening finding in a client who is experiencing acute alcohol withdrawal. Seizures can occur within 48 hours of cessation of alcohol intake and can lead to status epilepticus, brain damage, or death. Tachycardia, cramping, and elevated temperature are also common signs of alcohol withdrawal, but they are not as urgent as seizures.

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Correct Answer is B

Explanation

Choice A reason

While thinning of secretions can be a positive sign, it's not always visible. A decrease in peak inspiratory pressure is a more objective indicator of improved airway patency.

Choice B reason.

Peak inspiratory pressure is the maximum pressure required to push air into the lungs. If suctioning is effective, it will remove secretions and reduce airway resistance, leading to a decrease in peak inspiratory pressure

Choice C reason:

While a productive cough can indicate that secretions are being moved, it doesn't directly measure the effectiveness of suctioning.

Choice D reason:

Flattening of the artificial airway cuff: Flattening of the artificial airway cuff is not a relevant indicator of the effectiveness of suctioning. The cuff of an endotracheal tube is inflated to prevent air leaks around the tube and to maintain proper ventilation. It is not directly related to the effectiveness of suctioning.

A. The client fell because the assistive personnel did not place nonskid slippers on the client." B. The client does not appear to have any injuries resulting from the fall." C. "Client stated, 'I lost my balance and fell when I got out of bed to go to the bathroom'." D. "An incident report has been completed and sent to risk management."

Correct Answer is C

Explanation

The correct answer is C. The nurse should document factual and objective information about the incident, such as what the client said and what actions were taken by the nurse and other staff members. The nurse should not document opinions or assumptions about the cause of the fall, such as blaming the assistive personnel or stating that the client has no injuries without performing a thorough assessment. The nurse should also not document that an incident report was completed and sent to risk management, as this is confidential information that should not be part of the medical record.

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A nurse is caring for a client who is experiencing acute alcohol withdrawal. Which of the following findings is the nurse's priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is suctioning the airway of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following findings should the nurse identify as an indication that the suctioning has been effective?

Correct Answer is B

Explanation

A nurse is completing documentation in the medical record about a client who fell on the floor. Which of the following statements should the nurse include in the documentation?

Correct Answer is C

Explanation

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