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:
Genital herpes can be transmitted through viral shedding even when there are no visible lesions.
Choice B rationale:
Oil-based lubricants can weaken latex condoms, increasing the risk of condom breakage.
Choice C rationale:
Maintaining hydration is important during outbreaks to support the body's immune response.
Choice D rationale:
Acyclovir can help manage outbreaks, but it does not cure the infection.
Correct Answer is A
Explanation
Choice A rationale:
Clients with Parkinson's disease often have motor difficulties and slowed movements. Allowing extra time for activities of daily living (ADLs) can help them maintain independence and reduce frustration.
Choice B rationale:
Weight gain is not a common manifestation of Parkinson's disease or a primary concern in its management.
Choice C rationale:
Instructing the client to look down at the feet when walking is not accurate advice for Parkinson's disease. It's important to maintain an upright posture and look ahead to improve balance and gait.
Choice D rationale:
A low-protein diet is not generally recommended for clients with Parkinson's disease, as protein can affect the absorption of levodopa, a common medication used in its management.
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