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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Free Nursing Study Resources

Correct Answer is ["A","B","E"]

Explanation

Choice A reason: Avoiding submersion until the incision heals prevents infection in a new pacemaker site. This aligns with post-implant care, making it a correct instruction the nurse would include to ensure proper healing and device safety for the client.

Choice B reason: Reporting pulse rates below pacemaker settings indicates potential device failure, requiring prompt evaluation. This aligns with pacemaker monitoring, making it a correct instruction the nurse would teach the client to ensure device function and cardiac stability.

Choice C reason: Applying pressure over the generator doesn’t address weakness and may harm the device. Reporting low pulse rates is correct, making this incorrect, as it’s not a valid instruction for the nurse to include in pacemaker teaching.

Choice D reason: Pacemakers aren’t turned off for MRI; MRI-compatible devices or alternatives are used. Arm movement restriction is correct, making this incorrect, as it’s inaccurate compared to the nurse’s proper instructions for pacemaker care and MRI safety.

Choice E reason: Avoiding arm lifting above the shoulder for 8 weeks prevents lead dislodgement in a new pacemaker. This aligns with post-implant restrictions, making it a correct instruction the nurse would include to protect the device’s integrity.

A. Eating leafy green vegetables with a glass of water. B. Eating apple slices with carrots. C. Eating a steak with mushrooms. D. Eating calf’s liver with a glass of orange juice.

Correct Answer is D

Explanation

Choice A reason: Leafy greens contain iron, but water doesn’t enhance absorption; vitamin C does. Calf’s liver with orange juice maximizes absorption, making this incorrect, as it lacks the vitamin C component the nurse should teach to improve iron uptake in anemia.

Choice B reason: Apples and carrots have minimal iron and no vitamin C to enhance absorption. Calf’s liver with orange juice is optimal, making this incorrect, as it doesn’t provide iron or absorption enhancers compared to the nurse’s teaching for iron deficiency anemia.

Choice C reason: Steak is iron-rich, but mushrooms don’t significantly enhance absorption like vitamin C. Orange juice with liver is better, making this incorrect, as it’s less effective than the nurse’s recommendation to pair iron with a vitamin C source for anemia.

Choice D reason: Calf’s liver is high in iron, and orange juice’s vitamin C enhances non-heme iron absorption. This aligns with nutritional education for iron deficiency anemia, making it the correct choice for the nurse to teach the client to improve iron absorption effectively.

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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

A nurse teaches a client with a new permanent pacemaker. Which instructions would the nurse include in this client’s teaching? (Select all that apply)

Correct Answer is ["A","B","E"]

Explanation

The nurse is educating a patient with iron deficiency anemia about food sources high in iron and how to enhance the absorption of iron when eating these foods. What can the nurse inform the client would enhance the absorption?

Correct Answer is D

Explanation

A client with exacerbation of chronic obstructive pulmonary disease (COPD) is scheduled for a thoracentesis. Which nursing intervention would be appropriate for client safety?

A client admitted to the hospital with a suspected diagnosis of acute pancreatitis is being assessed by the nurse. Which assessment findings would be consistent with acute pancreatitis? (Select all that apply)

The nurse is providing discharge teaching for a client with newly diagnosed Crohn's disease about dietary measures to implement during exacerbation episodes. Which statement made by the client indicates a need for further instruction?

The nurse cares for clients in the outpatient clinic. Which client is MOST at risk for the syndrome of inappropriate antidiuretic hormone secretion (SIADH)?

A nurse in an emergency department is caring for a client who has a blood pressure of 254/139 mm Hg. The nurse recognizes that the client is in a hypertensive crisis. Which of the following actions should the nurse take first?