A nurse is caring for a client who is receiving mechanical ventilation following a stroke.
Which of the following actions should the nurse take?
Cluster nursing care activities.
Hyperoxygenate the client before suctioning.
Keep the room well lit to orient the client.
Maintain the client's PaCO2 at 50 mm Hg.
The Correct Answer is A
Choice A rationale:
Clustering nursing care activities minimizes disruptions to the client, reduces fatigue, and allows for periods of rest in between interventions.
Choice B rationale:
Hyperoxygenating the client before suctioning helps maintain adequate oxygenation and prevents hypoxia during the suctioning procedure.
Choice C rationale:
Keeping the room well lit is not necessary for a client on mechanical ventilation and can actually disturb their rest.
Choice D rationale:
Maintaining a specific PaCO2 level might be important for some clients, but this is not a general action applicable to all mechanically ventilated clients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Electroconvulsive therapy (ECT) is typically administered as a series of treatments, often ranging from 6 to 12 sessions, to achieve optimal therapeutic effects.
Choice B rationale:
ECT can provide relief from severe depressive symptoms, but it is not necessarily considered a "cure" for depression.
Choice C rationale:
ECT is not usually accompanied by antianxiety medication during the treatments.
Choice D rationale:
Recovery from ECT typically occurs within minutes after the treatment, not after 2 hours.
Correct Answer is A
Explanation
Choice A rationale:
Placing objects within the client's reach on the right side helps to compensate for the hemiparesis and facilitates the client's ability to independently access items.
Choice B rationale:
Encouraging the client to repeat phonetic sounds might be more appropriate for speech therapy and may not directly address hemiparesis.
Choice C rationale:
Pausing to allow the client time to respond to questions is a communication technique but does not address the physical effects of hemiparesis.
Choice D rationale:
Frequently orienting the client to time, place, and surroundings is important for cognitive support but does not specifically address hemiparesis.
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