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:
Clomiphene is used to induce ovulation in women with infertility. Hot flashes are a common side effect of clomiphene due to its impact on hormone levels. Clomiphene is a medication that stimulates ovulation by blocking estrogen receptors in the hypothalamus and pituitary gland. This causes an increase in the production of follicle-stimulating hormone (FSH) and luteinizing hormone (LH), which stimulate the growth and maturation of ovarian follicles. One of the common side effects of clomiphene is hot flashes, which are caused by the sudden drop in estrogen levels. Hot flashes can be mild or severe, and can occur at any time of the day or night. They usually last for a few minutes and can be accompanied by sweating, palpitations, anxiety, or nausea.
Choice B rationale:
Changes in taste are not a typical side effect of clomiphene.
Choice C rationale:
A dry cough is not typically associated with clomiphene.
Choice D rationale:
Migraine with aura is not typically associated with clomiphene.
Correct Answer is C
Explanation
Choice A rationale:
Increased serum amylase is a common finding in acute pancreatitis, and its decrease would be a positive sign. However, lipase is a more specific marker for pancreatic injury.
Choice B rationale:
Increased C-reactive protein is a marker of inflammation and would not necessarily indicate improvement in pancreatitis.
Choice C rationale:
Decreased serum lipase indicates improvement in the pancreatic injury and is a positive sign.
Choice D rationale:
Decreased platelets would not specifically indicate improvement in acute pancreatitis.
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