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A nurse is caring for four clients who are postoperative from surgery 24 hr ago. At 1200 the nurse assesses the clients. Which of the clients is the nurse’s priority?

A client who has a prescription for insulin and his premeal capillary blood glucose was 110 mg/dL and his post meal capillary blood glucose is now 160 mg/dL

A client whose blood pressure at 0800 was 138/86 mm Hg and at 1200 is 106/60 mm Hg

A client who reports pain as 4 on a scale of 1 to 10 at 0800 now reports pain as 6

A client whose wound drainage at 0800 was sanguineous and now it is serosanguineous

Answer and Explanation

The Correct Answer is B

A. A client who has a prescription for insulin, and his premeal capillary blood glucose was 110 mg/dL, and his post-meal capillary blood glucose is now 160 mg/dL:
While changes in blood glucose levels are important to monitor, the described change is not as significant as a sudden drop in blood pressure. The blood glucose levels in this scenario are still within a reasonable range.

B. A client whose blood pressure at 0800 was 138/86 mm Hg, and at 1200 is 106/60 mm Hg:
This is the priority client. The significant drop in blood pressure raises concerns about hypovolemia or circulatory issues, which require immediate attention to prevent complications such as inadequate organ perfusion.

C. A client who reports pain as 4 on a scale of 1 to 10 at 0800 and now reports pain as 6:
Pain management is important, but the change in pain intensity from 4 to 6, while indicating an increase, may not be as urgent as addressing a significant drop in blood pressure. Pain assessment and management can be addressed after stabilizing the client with the acute change.

D. A client whose wound drainage at 0800 was sanguineous, and now it is serosanguineous:
Changes in wound drainage color can be important for assessing the healing process, but a shift from sanguineous to serosanguineous is generally within the expected progression of wound healing. It may not require immediate intervention as compared to a significant drop in blood pressure.

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Correct Answer is D

Explanation

A. PEEP decreases the peak respiratory pressures:
PEEP may increase peak respiratory pressures, especially during inspiration, but its primary purpose is to prevent alveolar collapse and improve oxygenation.

B. “PEEP increases the number of breaths the patient takes on his own.”:
PEEP does not increase the number of breaths the patient takes. It primarily affects the quality of ventilation by preventing alveolar collapse.

C. “PEEP augments the patient’s overall tidal volumes.”:
PEEP does not necessarily increase overall tidal volumes. It focuses on maintaining positive pressure at the end of expiration to prevent alveolar collapse.

D. “PEEP improves oxygenation by keeping alveoli open after exhalation.”
Positive end-expiratory pressure (PEEP) is used in mechanical ventilation to maintain positive pressure in the airways and alveoli at the end of the respiratory cycle (expiration). This helps prevent alveolar collapse and improves oxygenation by keeping the alveoli open, particularly in patients with conditions like acute respiratory distress syndrome (ARDS). PEEP is commonly used to increase functional residual capacity (FRC) and improve oxygenation.

A. Instructions on how to change ventilator settings B. Instructions on mouth care C. Instructions to suction the client’s tracheostomy every 2 hr D. Instructions to place the client in a supine position

Correct Answer is B

Explanation

A. Instructions on how to change ventilator settings:
Ventilator settings are typically adjusted by respiratory therapists or healthcare providers based on the client's respiratory status. While nurses may be involved in monitoring, changing ventilator settings is not part of the routine nursing care bundle.

B. Instructions on mouth care
Mouth care is an important component of the ventilator care bundle to prevent ventilator-associated pneumonia (VAP). Proper oral hygiene, including regular mouth care, can help reduce the risk of infection.

C. Instructions to suction the client’s tracheostomy every 2 hr:
Suctioning frequency is determined based on the client's needs and is not a fixed component of the ventilator care bundle. Suctioning is performed as necessary to maintain airway patency.

D. Instructions to place the client in a supine position:
The positioning of the client may be individualized based on the clinical condition. However, placing the client in a supine position is not a fixed component of the ventilator care bundle. The emphasis is on practices that prevent complications associated with mechanical ventilation.

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A nurse is caring for four clients who are postoperative from surgery 24 hr ago. At 1200 the nurse assesses the clients. Which of the clients is the nurse’s priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A student is caring for a patient with positive end-expiratory pressure (PEEP) at 5 cm H20. The student asks “What is the purpose of PEEP?” which of the following is an appropriate response by the nurse?

Correct Answer is D

Explanation

A nurse is implementing the ventilator care bundle for a client who is receiving mechanical ventilation. Which of the following should the nurse expect to find in the bundle?

Correct Answer is B

Explanation

A nurse is providing discharge teaching for a client who has a new prescription for home oxygen. Which of the following should the nurse include in the teaching?

A nurse is preparing to administer dextrose 5% in water (DW) 150 mL IV to infuse over 3 hr. The drop factor of the manual IV tubing is 10 gtt. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Do not use a trailing zero.)

A nurse is assessing a client who has oxygen toxicity. Which of the following findings should the nurse expect?

A nurse has received morning report on the following four clients. Which of the following clients should the nurse assess first?

A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. The client pulls out his endotracheal tube. Which of the following actions should the nurse take first?

A nurse in a long-term care facility is planning care for several clients. Which of the following activities should the nurse delegate to the licensed practical nurse (LPN)?

A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan?