Exhibits

A client is admitted to the intensive care unit with multisystem organ dysfunction syndrome (MODS). The client is restless, febrile, and nauseated. Insulin is infusing at 5 units/hour per protocol to keep blood glucose less than 150 mg/dL (8.3 mmol/L). Dopamine is infusing at 5 mcg/kg/minute per protocol to keep mean arterial pressure (MAP) greater than 65 mm Hg. Serum blood glucose is 160 mg/dL and MAP is 66 mm Hg. The client is receiving oxygen at 50% via face mask and has an oxygen saturation of 92%. Which intervention should the nurse implement?

Reference Range:

Glucose [74 to 106 mg/dL (4.1 to 5.9 mmol/L)]

Administer famotidine 20 mg IV.

Titrate insulin infusion by 1 unit/hour.

Increase dopamine 2 mcg/kg.

Raise oxygen by 10 percent.

Answer and Explanation

The Correct Answer is B

A. Administer famotidine 20 mg IV. Famotidine is a histamine-2 receptor antagonist used for stress ulcer prophylaxis in critically ill patients. While this medication may be beneficial, it is not the priority intervention based on the insulin protocol and the client's blood glucose level.
B. Titrate insulin infusion by 1 unit/hour. The client’s blood glucose is 160 mg/dL, which falls within the 150–199 mg/dL range according to the insulin protocol. The protocol directs the nurse to increase the insulin drip rate by 1 unit/hour to maintain blood glucose levels below 150 mg/dL. This is the most immediate and appropriate action.
C. Increase dopamine 2 mcg/kg. The client’s MAP is 66 mmHg, which meets the protocol goal of keeping MAP >65 mmHg. There is no indication for increasing dopamine at this time, as the blood pressure is already within the target range.
D. Raise oxygen by 10 percent. The client is on 50% FiO₂ via a face mask with an oxygen saturation of 92%, which is adequate oxygenation for a critically ill patient. Increasing FiO₂ unnecessarily may contribute to oxygen toxicity and is not required based on current oxygenation status.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. Suction subglottic area above the ETT cuff before entering the ETT. While subglottic suctioning helps prevent ventilator-associated pneumonia (VAP) by removing pooled secretions, it does not directly improve oxygenation during deep endotracheal suctioning. The priority is to optimize oxygenation before and after suctioning.
B. Use the ventilator settings to stack breaths prior to suctioning. Pre-oxygenating the client by delivering additional breaths via the ventilator helps prevent hypoxia during suctioning. Closed suction systems momentarily interrupt airflow, which can lead to oxygen desaturation. Providing 100% FiO₂ for 30–60 seconds before suctioning helps ensure adequate oxygenation and reduces complications.
C. Rinse suction catheters with normal saline between each suction pass. Flushing the catheter keeps it clean and patent, but it does not enhance oxygenation. Normal saline instillation before suctioning is not recommended, as it can increase infection risk and worsen secretion mobilization.
D. Suction for 30 seconds with each pass of the suction catheter. Prolonged suctioning can cause severe hypoxia, bradycardia, and airway trauma. Suction passes should be limited to 10–15 seconds to minimize complications. If additional suctioning is needed, the client should be reoxygenated between passes.

A. Normal sinus rhythm (NSR) at 84 beats/minute. B. Regular rhythm with consistent pacemaker capture. C. Return of elevated ST segment to the baseline. D. Increased frequency of QRS complexes.

Correct Answer is A

Explanation

A. Normal sinus rhythm (NSR) at 84 beats/minute. The goal of cardioversion for atrial fibrillation (AFib) is to restore a normal sinus rhythm (NSR). NSR indicates that the atria and ventricles are depolarizing in a coordinated manner, reducing the risk of thromboembolism, stroke, and hemodynamic instability. A heart rate of 84 beats/minute is within the normal range, confirming the success of the procedure.
B. Regular rhythm with consistent pacemaker capture. Cardioversion is used to restore normal rhythm in AFib, not to manage pacemaker function. A pacemaker is not part of standard AFib cardioversion unless the client has underlying conduction issues requiring pacing.
C. Return of elevated ST segment to the baseline. ST elevation suggests acute myocardial infarction (MI), which is unrelated to atrial fibrillation or cardioversion. Cardioversion does not treat ST elevation or myocardial ischemia, making this an incorrect indicator of success.
D. Increased frequency of QRS complexes. An increase in QRS frequency suggests tachycardia, which would indicate treatment failure rather than success. The goal of cardioversion is to restore a normal, controlled heart rate and rhythm, not to increase the number of ventricular contractions.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A client has been treated for uncontrolled atrial fibrillation with cardioversion. Following the cardioversion, which assessment finding indicates to the nurse that the desired outcome was achieved?

Correct Answer is A

Explanation

Exhibits Which other labs would be helpful for the treatment of diabetic ketoacidosis (DKA)? Select all that apply.

A client is brought to the emergency department (ED) following a motor vehicle collision with blunt trauma to the chest. Which finding should the nurse report immediately to the healthcare provider (HCP)?

Exhibits Based on the client's diagnosis, which results does the nurse expect in the blood gas? Select all that apply

A client has a chest tube connected to a closed water-seal drainage system with suction. Which equipment should the nurse always have available at the client's bedside?