A patient with acute lung failure has been on a ventilator for 3 days and is being considered for weaning. When entering the room, the ventilator inoperative alarm sounds. What action should the nurse take FIRST?

Troubleshoot the ventilator until the problem is found.

Take the patient off the ventilator and manually ventilate.

Call the respiratory therapist for help.

Silence the ventilator alarms until the problem is resolved.

Answer and Explanation

The Correct Answer is B

Choice A reason: Troubleshooting the ventilator delays oxygenation in a patient with acute lung failure. Manual ventilation ensures immediate breathing, making this incorrect, as it’s less urgent than the nurse’s priority to maintain the patient’s airway and oxygenation during an alarm.

Choice B reason: Manually ventilating the patient after disconnecting from the inoperative ventilator ensures oxygenation in acute lung failure. This aligns with emergency respiratory protocols, making it the correct first action the nurse should take to address the ventilator alarm.

Choice C reason: Calling the respiratory therapist is important but delays immediate oxygenation needed during a ventilator failure. Manual ventilation is the priority, making this incorrect, as it postpones the nurse’s critical action to ensure the patient’s breathing is supported.

Choice D reason: Silencing alarms without addressing the ventilator failure risks hypoxia in a lung failure patient. Manual ventilation is urgent, making this incorrect, as it’s unsafe compared to the nurse’s priority of ensuring oxygenation during the inoperative alarm.

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Correct Answer is D

Explanation

Choice A reason: Analyzing care levels is important, but the nurse’s negligence lies in not addressing the critical magnesium level. Reporting to the practitioner is the appropriate action, making this incorrect, as it’s less specific than the failure to act on a critical lab result.

Choice B reason: Respecting patient wishes relates to DNR but doesn’t negate the need to report critical labs for non-resuscitative care. Failure to act is the issue, making this incorrect, as it misapplies the DNR to the nurse’s duty to address the magnesium level.

Choice C reason: Wrongful death assumes patient harm or death, which isn’t indicated here. Failure to act on the critical magnesium level is the negligence, making this incorrect, as it overstates the outcome compared to the nurse’s inaction on the lab result.

Choice D reason: Failure to take appropriate action, such as reporting a critical magnesium level of 1.1 mEq/L, is negligent, regardless of DNR status. This aligns with nursing standards, making it the correct action the nurse neglected, as critical labs require practitioner notification.

A. Ensuring that the concentration is no greater than 1 mEq/10mL (mmol/10 mL) of solution. B. Checking IV access for blood return after the infusion. C. Pushing the drug as a bolus slowly over 5 minutes. D. Initiating the IV in a hand vein for rapid access. E. Keeping the client NPO during drug treatment. F. Using an IV controller to deliver the drug.

Correct Answer is ["B","F"]

Explanation

Choice A reason: Potassium concentration should be 10-20 mEq/100mL, not 1 mEq/10mL, to avoid irritation. Using an IV controller is correct, making this incorrect, as it’s an unsafe dilution compared to the nurse’s best practices for safe parenteral potassium administration.

Choice B reason: Checking IV access for blood return post-infusion ensures the potassium was delivered correctly, preventing extravasation. This aligns with IV therapy safety, making it a correct best practice the nurse should follow when administering parenteral potassium to the client.

Choice C reason: Pushing potassium as a bolus is dangerous, risking cardiac arrhythmias; it must be infused slowly. IV controller use is correct, making this incorrect, as it’s unsafe compared to the nurse’s best practices for administering potassium to a hypokalemic client.

Choice D reason: Hand veins are unsuitable for potassium, which is irritating and requires larger veins. Checking blood return is correct, making this incorrect, as it risks complications compared to the nurse’s best practices for safe potassium administration in the client.

Choice E reason: Keeping the client NPO is unnecessary for potassium administration, which addresses hypokalemia, not digestion. IV controller use is correct, making this incorrect, as it’s irrelevant to the nurse’s best practices for delivering parenteral potassium safely to the client.

Choice F reason: Using an IV controller ensures a safe, steady infusion rate for potassium, preventing cardiac complications. This aligns with medication safety protocols, making it a correct best practice the nurse should employ when administering parenteral potassium to the hypokalemic client.

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A patient with acute lung failure has been on a ventilator for 3 days and is being considered for weaning. When entering the room, the ventilator inoperative alarm sounds. What action should the nurse take FIRST?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The laboratory notifies the night nurse that the patient has a critical magnesium level of 1.1 mEq/L. The patient has a do-not-resuscitate order. The nurse does not inform the practitioner because of the patient’s code status. In doing so, the nurse is negligent for which action?

Correct Answer is D

Explanation

Which actions are considered best practices for the nurse to use during the administration of parenteral potassium to a client with a serum potassium level of 1.9 mEq/L (mmol/L)? (Select all that apply)

Correct Answer is ["B","F"]

Explanation

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