Before weaning a client from a ventilator, which assessment parameter(s) is most important for the nurse to assess?

Fluid intake for the last 24 hours

Baseline arterial blood gas (ABG) levels

Blood pressure and heart rate

Electrocardiogram (ECG) results

Answer and Explanation

The Correct Answer is B

Choice A reason: Fluid intake over 24 hours affects hydration and cardiovascular status but is not the primary parameter for ventilator weaning. Adequate fluid status supports hemodynamics, but weaning success depends on respiratory parameters like oxygenation and CO2 clearance, which are directly assessed by arterial blood gases, making fluid intake secondary.

Choice B reason: Baseline arterial blood gas (ABG) levels are critical before weaning from a ventilator. ABGs assess oxygenation (PaO2), CO2 levels (PaCO2), and acid-base balance, indicating the patient’s ability to maintain adequate ventilation and gas exchange independently. Normal or stable ABG values are essential to ensure successful weaning without respiratory failure.

Choice C reason: Blood pressure and heart rate reflect cardiovascular stability, which is important during weaning to ensure the patient tolerates increased respiratory effort. However, these are secondary to respiratory parameters. ABGs directly measure lung function, making them the priority to confirm the patient can breathe independently without ventilator support.

Choice D reason: Electrocardiogram (ECG) results assess cardiac rhythm and ischemia, which are relevant in critically ill patients. However, for ventilator weaning, the focus is on respiratory function. ECG abnormalities may warrant attention, but ABGs are the primary parameter to evaluate gas exchange and respiratory adequacy, making ECG less critical in this context.

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Correct Answer is C

Explanation

Choice A reason: Infection is a significant risk in burns due to loss of the skin barrier, allowing pathogens like Pseudomonas to invade. However, in the acute phase, airway obstruction from head and neck burns is more immediately life-threatening. Infection control is critical but secondary to ensuring a patent airway in the ABCDE approach.

Choice B reason: Paralytic ileus can occur in burn patients due to stress response or hypokalemia, impairing gastrointestinal motility. While serious, it is not an immediate threat to life compared to airway obstruction. The ABCDE approach prioritizes airway, making ileus a lower priority in the acute management of head and neck burns.

Choice C reason: Extensive burns to the head, neck, and chest pose a high risk of airway obstruction due to edema from thermal injury to the upper airway. Swelling can rapidly compromise breathing, requiring urgent assessment and possible intubation. In the ABCDE approach, airway is the top priority, making this the critical focus.

Choice D reason: Fluid imbalance, particularly hypovolemia, is a major concern in burns due to plasma leakage. While critical, it is addressed after airway and breathing in the ABCDE approach. Airway obstruction from head and neck burns can cause rapid death, making it the priority over fluid resuscitation in the initial assessment.

A. Stage 4 B. Stage 3 C. Stage 2 D. Stage 1

Correct Answer is B

Explanation

Choice A reason: Stage 4 chronic kidney disease is characterized by a GFR of 15-29 mL/min/1.73 m², indicating severe kidney dysfunction. The kidneys have limited ability to filter waste, leading to accumulation of toxins, fluid overload, and electrolyte imbalances such as hyperkalemia or metabolic acidosis. A GFR of 43 mL/min/1.73 m² is higher, reflecting moderate rather than severe impairment, making Stage 4 incorrect.

Choice B reason: Stage 3 chronic kidney disease is defined by a GFR of 30-59 mL/min/1.73 m², subdivided into Stage 3A (45-59) and Stage 3B (30-44). A GFR of 43 falls within Stage 3B, indicating moderate kidney damage. This stage involves reduced filtration capacity, potentially causing symptoms like edema, hypertension, or early uremia due to impaired waste excretion and fluid balance regulation.

Choice C reason: Stage 2 chronic kidney disease corresponds to a GFR of 60-89 mL/min/1.73 m², indicating mild kidney dysfunction. Patients may be asymptomatic, but structural kidney damage may be present, detectable via proteinuria or imaging. A GFR of 43 is lower, indicating more significant impairment with increased risk of complications like anemia or bone disease, ruling out Stage 2.

Choice D reason: Stage 1 chronic kidney disease is defined by a GFR ≥90 mL/min/1.73 m² with evidence of kidney damage, such as proteinuria or abnormal imaging. Kidney function is nearly normal, and symptoms are typically absent. A GFR of 43 indicates moderate to severe kidney damage, far below the normal range, making Stage 1 an incorrect classification for this client.

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Before weaning a client from a ventilator, which assessment parameter(s) is most important for the nurse to assess?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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