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 C
Explanation
Choice A rationale:
Decreased muscle mass can be a normal age-related change in older adults and is not necessarily indicative of elder maltreatment.
Choice B rationale:
White circles surrounding the cornea (arcus senilis) is a common age- related finding and is not necessarily indicative of elder maltreatment.
Choice C rationale:
The presence of urine odor on the client's clothes could indicate neglect or inadequate care and should be further investigated.
Choice D rationale:
Nodules on the metacarpal joints may be related to osteoarthritis, which is a common condition in older adults and may not necessarily indicate elder maltreatment.
Correct Answer is A
Explanation
Choice A rationale:
Sertraline is an antidepressant medication known as a selective serotonin reuptake inhibitor (SSRI). One of the potential side effects of SSRIs is sexual dysfunction, including erectile dysfunction.
Choice B rationale:
Vancomycin is an antibiotic and is not typically associated with erectile dysfunction.
Choice C rationale:
Topiramate is an anticonvulsant medication and is not typically associated with erectile dysfunction.
Choice D rationale:
Polyethylene glycol is a laxative and is not typically associated with erectile dysfunction.
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