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.

Answer and Explanation

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.

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

Explanation

Rationale:

Place on a Low-protein diet: A low-protein diet is often prescribed in clients with hepatic encephalopathy to reduce ammonia production from protein metabolism. With an ammonia level of 150 mcg/dL and signs of chronic liver disease, this is appropriate.
Daily abdominal girth measurements: This client has a distended abdomen with dullness to percussion, suggesting ascites. Measuring abdominal girth daily helps monitor fluid accumulation and response to diuretics or fluid restriction.
Daily weights: Weight tracking is essential in clients with ascites or fluid imbalance, common in cirrhosis. It provides a sensitive indicator of fluid retention or loss over time.
Liver biopsy: With thrombocytopenia (platelets 120,000/mm³), active GI bleeding, and coagulopathy likely due to cirrhosis, liver biopsy poses a high bleeding risk and is not appropriate in this unstable condition.
Administer lactulose: Lactulose is a first-line treatment for hepatic encephalopathy. It works by trapping ammonia in the colon and promoting its excretion. This is essential given the client's elevated ammonia level and risk for mental status changes.
Liver ultrasound: A liver ultrasound is a non-invasive imaging tool to evaluate liver size, structure, and presence of masses or ascites. It is safe and appropriate in this client's condition and can guide further management.

A. "I changed the floor plan of our home to accommodate my parent’s wheelchair." B. "I’m so stressed out that it makes it difficult for me to manage everything." C. "At times, I get so frustrated with how to care for my parents." D. "I am learning to take care of my parents as I go."

Correct Answer is A

Explanation

Rationale:
A. "I changed the floor plan of our home to accommodate my parent’s wheelchair.": This statement reflects proactive planning and adjustment to meet the needs of the client’s parents, indicating that the individual has accepted the caregiver role and is taking concrete steps to fulfill it effectively.

B. "I’m so stressed out that it makes it difficult for me to manage everything.": This expresses emotional overwhelm and difficulty coping, suggesting that the client is still struggling with the demands of caregiving and has not yet fully adjusted to or accepted the new role.

C. "At times, I get so frustrated with how to care for my parents.": While frustration is a normal part of caregiving, this statement reflects ongoing emotional conflict, which may suggest partial adaptation but not full acceptance of the caregiving role.

D. "I am learning to take care of my parents as I go.": This shows a willingness to adapt, but it suggests the client is still in the early stages of role transition. Acceptance involves not just learning but also implementing sustainable changes to accommodate the new responsibilities.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a male client in the emergency department. Exhibits The nurse is planning care for this client. For each potential prescription, specify if it is anticipated or contraindicated:

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

Explanation

A nurse is caring for a client who recently assumed the role of caregiver for their aging parents who have chronic illnesses. The nurse should identify that which of the following statements by the client indicates acceptance of the role change?

Correct Answer is A

Explanation

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