A patient is on a ventilator. Which situation warrants immediate intervention by the nurse?
ABG
pH 7.35-7.45
pa02 80-100 mg Hg
PC02 35-45 mm Hg
PHCO3 22-26meQ/L
The ABG results are pH 7.41. Pa02 93. PaCO2 35, and HCO3 24.
The client's pulse oximeter reading is 91% with a consistent waveform
There is no manual resuscitation bag is at the client's bedside.
The patient is receiving continuous IV sedation at 150 mL/hr. There's currently 100 ml remaining of the infusion.
The Correct Answer is C
A. The ABG results are pH 7.41, PaO2 93, PaCO2 35, and HCO3 24: These ABG values are all within normal ranges:
pH 7.35–7.45 (normal)
PaO2 80–100 mmHg (normal)
PaCO2 35–45 mmHg (normal)
HCO3 22–26 mEq/L (normal)
These results indicate stable respiratory function and do not warrant immediate intervention.
B. The client's pulse oximeter reading is 91% with a consistent waveform: While 91% is slightly lower than the ideal oxygen saturation (usually above 92%–94%), it is still above the critical threshold of 90%. This could be an acceptable level in some patients on a ventilator, particularly if there are no signs of distress or other abnormalities.
C. There is no manual resuscitation bag at the client's bedside: This is a critical situation. A manual resuscitation bag (Ambu bag) is essential for emergency resuscitation if the ventilator fails or if there is an unexpected issue with the patient's airway. Not having a manual resuscitation bag at the bedside is a safety concern that warrants immediate intervention, as it could delay life-saving measures in an emergency.
D. The patient is receiving continuous IV sedation at 150 mL/hr. There's currently 100 mL remaining of the infusion: While it's important to monitor IV sedation infusions, this situation does not immediately warrant intervention. The nurse can track the remaining infusion and ensure there is an adequate supply or order a new infusion if necessary.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Encourage the use of sunglasses when outside: Sunglasses are useful for reducing glare and light sensitivity, but they do not address the underlying cause of diplopia (double vision) in Multiple Sclerosis (MS). Diplopia is often due to neurological damage affecting the eye muscles or nerve pathways, not from light sensitivity.
B. Assess for conjunctival bleeding: Conjunctival bleeding (bleeding under the eye's clear surface) is not related to diplopia. Diplopia in MS is caused by problems with the nerves or muscles controlling eye movement, and assessing for conjunctival bleeding would not help in managing the double vision.
C. Alternate the use of an eye patch on each eye: Diplopia in MS is commonly caused by eye misalignment due to nerve damage. Using an eye patch on one eye at a time can temporarily help by blocking vision in one eye, allowing the brain to focus and alleviating the perception of double vision. Alternating the patch between eyes is a common strategy to manage diplopia while treating the underlying neurological issues.
D. Apply cool compresses for pain relief: Cool compresses might help with general eye discomfort, but they do not directly address diplopia. Diplopia due to MS is usually caused by muscle or nerve issues rather than discomfort that could be relieved by cool compresses.
Correct Answer is C
Explanation
A. Administering aggressive medical interventions to prolong life: In the end stages of Huntington's Disease, aggressive medical interventions are generally not the priority. Huntington's is a progressive neurodegenerative disease, and prolonging life without regard to the patient's quality of life is usually not the focus. The emphasis in end-of-life care is on comfort and symptom management rather than aggressive treatments.
B. Encouraging the patient to engage in physical therapy and exercise: While physical therapy can be important earlier in the disease progression to help maintain function and mobility, in the end stages of Huntington's Disease, the patient's focus is more on comfort care. At this point, physical therapy may not be practical or helpful in improving quality of life, so it is not the primary consideration.
C. Providing comfort care and managing symptoms according to patient's wishes: This is correct. The most important consideration in end-of-life care for a patient with Huntington's Disease is to focus on comfort and symptom management. This includes addressing pain, managing emotional and psychological symptoms, and ensuring that care aligns with the patient's wishes, values, and goals. End-of-life care should prioritize maintaining dignity and ensuring the patient's comfort.
D. Providing respite care and support for the patient's family: While providing respite care and family support are very important aspects of caregiving, the most important consideration is the patient's comfort and managing symptoms in alignment with their wishes. Respite care for the family is important but is not the central focus of end-of-life care for the patient.
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