A nurse is caring for a client who is mechanically ventilated and is agitated. The nurse notices the client attempts to reach the endotracheal tube. Which of the following actions should the nurse take?
Verify the alarm settings on the ventilator.
Turn on the television.
Obtain a prescription for a vest restraint.
Administer a sedative medication.
The Correct Answer is D
Rationale:
A. Verify the alarm settings on the ventilator: Ensuring alarms are properly set is a routine safety check but does not directly address the client's agitation or risk of self-extubation. It is important but not the priority action in this scenario.
B. Turn on the television: Providing distraction may help reduce mild anxiety but is insufficient for managing significant agitation in a mechanically ventilated client who may become dangerous to themselves if they pull out the endotracheal tube.
C. Obtain a prescription for a vest restraint: Physical restraints should be a last resort after attempting less restrictive methods. Using restraints without addressing the underlying cause of agitation (e.g., discomfort, anxiety, pain) can increase distress and injury risk.
D. Administer a sedative medication: Sedation is appropriate for a mechanically ventilated client who is agitated and at risk for self-extubation. Sedatives help ensure patient comfort, reduce anxiety, and promote ventilator synchrony while protecting the airway.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Rationale:
A. Distended neck veins: Distended neck veins are typically associated with fluid volume excess, such as in heart failure or hypervolemia. In hypovolemia, the central venous pressure is low, often resulting in flat or collapsed neck veins due to the decreased circulating blood volume and reduced venous return.
B. Rapid pulse rate: Tachycardia is a key early sign of hypovolemia, as the heart attempts to compensate for decreased blood volume by increasing the heart rate to maintain adequate cardiac output. This compensatory mechanism helps preserve perfusion to vital organs during volume loss.
C. Urine output 45 mL/hr: A urine output of 45 mL/hr is considered adequate and within the normal range for an adult. In hypovolemia, renal perfusion typically decreases, often leading to oliguria (urine output less than 30 mL/hr), which would be a more specific indicator of fluid deficit.
D. Decreased respiratory rate: Hypovolemia generally triggers an increase in respiratory rate (tachypnea) as a compensatory response to improve oxygen delivery and perfusion. A decreased respiratory rate would be unusual and not characteristic of a volume-depleted state.
Correct Answer is D
Explanation
Rationale:
A. Maintain the head of the bed greater than 45°: Elevating the head of the bed beyond 30° increases pressure and shear forces on the sacrum, contributing to skin breakdown. The bed should be maintained at the lowest elevation necessary to reduce pressure injury risk.
B. Place a donut-shaped cushion under the client’s sacrum: Donut-shaped cushions can impede blood flow and concentrate pressure on surrounding tissues, increasing the risk of pressure injuries rather than preventing them. Specialty foam or gel cushions are preferred for pressure redistribution.
C. Massage bony prominences three times daily: Massaging over bony areas is contraindicated as it may cause further tissue damage in areas already at risk for pressure injury. Prevention strategies focus on pressure relief, skin protection, and improved circulation without direct trauma.
D. Apply moisturizer to damp skin after bathing: Applying moisturizer to slightly damp skin helps retain moisture, prevents dryness and cracking, and maintains skin integrity. This is an evidence-based practice in pressure injury prevention, especially for clients with fragile or at-risk skin.
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