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. Urinary retention can occur in Guillain-Barre Syndrome due to autonomic dysfunction, but it is not the most life-threatening complication.
B. Hypertension may be seen as part of autonomic instability in GBS, but it is usually not the primary concern.
C. Hyperglycemia is not a typical complication of GBS itself, unless related to treatments like IV corticosteroids (which are not first-line therapy for GBS) or comorbid conditions.
D. Guillain-Barre Syndrome causes progressive ascending paralysis, which can eventually involve the respiratory muscles. Monitoring for respiratory failure is critical, as it can develop rapidly and requires immediate intervention, such as mechanical ventilation.

A. variant B. Chronic stable C. Nocturnal D. Unstable

Correct Answer is D

Explanation

A. Variant angina: Also known as Prinzmetal's angina, this type of angina is caused by a spasm in the coronary arteries, which can temporarily restrict blood flow to the heart. While it can be severe, it is typically not associated with an impending myocardial infarction (MI). It often occurs at rest and is usually relieved with medications like nitrates or calcium channel blockers.

B. Chronic stable angina: This is the most common type of angina and occurs with physical exertion or emotional stress, typically following a predictable pattern. The pain is generally relieved with rest or nitroglycerin and is not usually associated with an impending myocardial infarction. Chronic stable angina is more of a symptom of underlying coronary artery disease (CAD) rather than an emergency situation.

C. Nocturnal angina: This occurs during sleep or while at rest, and it may be associated with coronary artery disease, but it is generally not an indicator of an impending MI. It can sometimes be relieved by sleeping in an upright position or using medications such as nitrates.

D. Unstable angina: This type of angina is the most concerning because it occurs unexpectedly and can happen at rest, with minimal physical activity, or at night. The pain is more severe, lasts longer, and may not be relieved by rest or nitroglycerin. Unstable angina is considered a medical emergency and is closely related to an impending myocardial infarction (MI). It signifies that a plaque in the coronary artery is unstable and may rupture, leading to a clot formation, which can completely block the artery and result in a heart attack.

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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)

Nursing Test Bank

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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