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 D
Explanation
Choice A rationale:
Other family members or close contacts may consider immunization, but it is not directly related to the client's ALS diagnosis.
Choice B rationale:
Since the client has a new diagnosis of ALS, the immediate focus should not be on selling their home, but rather on understanding and managing the disease.
Choice C rationale:
Requiring hospice care immediately is not a standard recommendation for a client with ALS. The client's disease progression and needs will be assessed to determine the appropriate level of care.
Choice D rationale:
Creating a living will is important for clients with a terminal illness like ALS, as it allows them to express their wishes for medical treatment and care preferences in advance.
Correct Answer is B
Explanation
Choice A rationale:
Upper abdominal pain is not a typical manifestation of diverticulitis. It is more commonly associated with conditions affecting the upper gastrointestinal tract.
Choice B rationale:
Rationale: Diverticulitis is characterized by inflammation or infection of diverticula (small pouches) in the colon. Manifestations of diverticulitis can include abdominal pain (usually left lower quadrant), fever, nausea, vomiting, and changes in bowel habits.
Abdominal distension may indicate worsening inflammation or complication of diverticulitis.
Choice C rationale: Clay-colored stools are more characteristic of liver or bile duct disorders, not diverticulitis.
Choice D rationale: Gastric reflux is not a common manifestation of diverticulitis. It is more related to gastroesophageal reflux disease (GERD) or other upper gastrointestinal issues.
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