A patient is in the progressive care unit on a ventilator. Which intervention(s) should the nurse implement? (SELECT ALL THAT APPLY)

Collaborate frequently with the respiratory therapist

Adjust the ventilator settings based on the client's level of consciousness

Document the patient's pulse oximetry once every shift

Ensure that a bag valve mask (BVM) with face mask is at the bedside

Assess the client's respiratory status hourly & as needed

Answer and Explanation

Correct Answer : A,D,E

A. Collaborate frequently with the respiratory therapist: Frequent collaboration with the respiratory therapist is essential to ensure the ventilator settings are appropriate for the patient's needs and to make adjustments as needed based on the patient's condition.

B. Adjust the ventilator settings based on the client's level of consciousness: While it’s important to monitor the patient’s level of consciousness, adjusting ventilator settings should primarily be done based on the patient's respiratory parameters (e.g., oxygenation, ventilation, lung mechanics), not solely on their level of consciousness. Ventilator settings should be adjusted by the respiratory therapist or physician as appropriate.

C. Document the patient's pulse oximetry once every shift: Pulse oximetry should be monitored and documented more frequently than once per shift, especially for a patient on a ventilator. Continuous monitoring is essential to assess oxygenation status and detect changes in the patient’s condition.

D. Ensure that a bag valve mask (BVM) with face mask is at the bedside: A BVM with face mask is an essential emergency equipment for a patient on a ventilator in case of ventilator failure or the need for resuscitation. Having it readily available ensures quick response in an emergency.

E. Assess the client's respiratory status hourly & as needed: Frequent assessment of the patient's respiratory status is critical for identifying any changes in condition, such as distress, ventilator malfunction, or need for adjustments. Monitoring should occur at least hourly and more frequently if the patient's condition requires it.

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Correct Answer is D

Explanation

A. Calling the physician is important if the patient’s condition worsens or if the chest pain persists after the full protocol of nitroglycerin administration (usually up to 3 doses, 5 minutes apart). However, this is not the immediate next action.
B. Incorrect dosage. The standard dose of sublingual nitroglycerin is 0.4 mg. Giving 4 mg would be a serious overdose and unsafe.
C. Increasing oxygen might be appropriate if the patient is hypoxic (e.g., low O₂ saturation), but this is not automatically done without assessing vitals first.
D. Before administering a second dose of nitroglycerin, it is essential to re-check the patient’s blood pressure and other vital signs. Nitroglycerin can cause hypotension, and giving another dose without verifying stability can be dangerous.

A. You will be back to your normal functioning approximately 1 week after the IVIG infusions." B. "IVIG will lessen the muscle weakness, but you will never achieve full motor strength and function. C. You will develop respiratory failure before the IVIG treats the muscle weakness, that is why you are in the hospital. D. VIG will be administered over the next 3-5 days, and side effects include flu-like symptoms.

Correct Answer is D

Explanation

A. "You will be back to your normal functioning approximately 1 week after the IVIG infusions.": The recovery process from Guillain-Barré Syndrome (GBS) can vary widely among individuals. It typically takes weeks to months for patients to recover full motor strength and function. The idea of returning to normal functioning in just one week after IVIG treatment is unrealistic.

B. "IVIG will lessen the muscle weakness, but you will never achieve full motor strength and function.": While recovery from GBS can be slow, many patients do recover fully or nearly fully with appropriate treatment, including IVIG. IVIG is used to shorten the duration of the illness and improve outcomes, but it does not guarantee permanent muscle weakness.

C. "You will develop respiratory failure before the IVIG treats the muscle weakness, that is why you are in the hospital.": This is not true for all patients. While Guillain-Barré Syndrome can lead to respiratory failure in some cases due to muscle weakness affecting the diaphragm and respiratory muscles, it does not mean that all patients will develop respiratory failure before treatment. IVIG is administered early to prevent severe complications, but this is not a universal scenario.

D. "VIG will be administered over the next 3-5 days, and side effects include flu-like symptoms.": Intravenous immunoglobulin (IVIG) treatment for GBS typically requires administration over a 3-5 day period. Common side effects of IVIG include flu-like symptoms, such as fever, chills, headache, and muscle aches. These symptoms are generally mild and transient.

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A patient is in the progressive care unit on a ventilator. Which intervention(s) should the nurse implement? (SELECT ALL THAT APPLY)

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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