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Exhibits

Based on the client's status at 1400, the nurse should plan to do which of the following? Select all that apply.

Increase the fractional concentration of Inspired oxygen

Change the ventilator settings to continuous positive airway pressure (CPAP)

Increase the respiratory rate

Continue weaning the ventilator as ordered

Decrease the tidal volume

Alert the provider of the blood gas values

Switch the ventilator to pressure control

Answer and Explanation

Correct Answer : A,F,G

A.   Increase the fractional concentration of Inspired oxygen: As the partial pressure of oxygen (PaO) has decreased to 64 mm Hg from 99 mm Hg, and the oxygen saturation may drop, it's necessary to increase the fraction of inspired oxygen (FiO2) to maintain adequate oxygenation.
B.   Change the ventilator settings to continuous positive airway pressure (CPAP): CPAP is not typically used in patients who are intubated. CPAP is a non-invasive ventilation mode used for patients with respiratory distress who are breathing spontaneously. In this case, the patient is intubated and requires mechanical ventilation, so CPAP is not appropriate.
C.   Increase the respiratory rate: While the respiratory rate has decreased from 15 to 13 breaths/minute, it's important to maintain a careful balance when adjusting ventilator settings. Increasing the respiratory rate may not be necessary at this point, especially if the patient is still oxygenating adequately. Moreover, the primary concern appears to be hypoxemia rather than hypoventilation.
D.   Continue weaning the ventilator as ordered: While weaning the patient off the ventilator is a goal, it may not be appropriate at this time, especially with the worsening blood gas values
indicating respiratory insufficiency. Continuing the weaning process could potentially exacerbate respiratory failure.

E. Decrease the tidal volume: Decreasing the tidal volume could worsen ventilation-perfusion matching and exacerbate hypoxemia. This approach might be considered in certain cases of acute respiratory distress syndrome (ARDS) or in patients with severe lung injury, but it's not typically indicated in this scenario without further assessment.

F. Alert the provider of the blood gas values: The nurse should inform the provider about the changes in blood gas values, especially the decrease in PaO2 and the increase in PaCO2, which indicate worsening respiratory status and potential respiratory acidosis.

G. Switch the ventilator to pressure control: Given the deterioration in respiratory status with an increase in PaCO2 and decrease in PaO2, switching to pressure control ventilation may provide better control over the patient's ventilation and oxygenation, especially in cases of acute
respiratory failure.

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Correct Answer is C

Explanation

A. Offer the client oral fluids. Offering fluids is important but is not directly related to turning the client or managing the urinary catheter.
B. Assess the breath sounds. Assessing breath sounds is beyond the scope of practice for a UAP.

C. Empty the urinary drainage bag. This action helps maintain catheter function and reduces the risk of infection by preventing urine from backing up in the bladder.
D. Feed the client a snack. Feeding the client is important but is not related to turning the client or managing the urinary catheter.

A. Test the fluid on the dressing for glucose. B. Mark the drainage area with a pen and continue to monitor. C. Change the dressing using a compression bandage. D. Document the findings in the electronic medical record.

Correct Answer is A

Explanation

A. Test the fluid on the dressing for glucose.
This is the correct action. Clear fluid on a dressing after lumbar spinal surgery could indicate a cerebrospinal fluid (CSF) leak. Testing the fluid for glucose is essential because CSF contains glucose, whereas normal wound drainage does not. A positive glucose test would confirm the presence of CSF, indicating a potential complication that requires immediate medical attention.

B. Mark the drainage area with a pen and continue to monitor.
While monitoring the size of the drainage area can be useful, it is not the immediate priority. The nurse should first determine whether the clear fluid is CSF.

C. Change the dressing using a compression bandage.
Changing the dressing might be necessary, but using a compression bandage without first identifying the nature of the fluid could be inappropriate and potentially harmful if the fluid is CSF.

D. Document the findings in the electronic medical record.
Documentation is important, but it is not the immediate action. The nurse needs to identify the nature of the fluid first.

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Exhibits

The nurse is implementing solutions to provide care.

Choose the most likely options for the information missing from the statement(s) by selecting from the lists of options provided.

The nurse determines that the client's is still having an adverse reaction resulting in symptoms of dropdown
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Exhibits Based on the client's status at 1400, the nurse should plan to do which of the following? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse instructs an unlicensed assistive personnel (UAP) to turn an immobilized older client with an indwelling urinary catheter every two hours. Which additional action should the nurse instruct the UAP to take each time the client is turned?

Correct Answer is C

Explanation

The nurse identifies the presence of clear fluid on the surgical dressing of a client who just returned to the unit following lumbar spinal surgery. Which action should the nurse implement immediately?

Correct Answer is A

Explanation

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A nurse is planning care for a client who is experiencing acute mania. Which of the following actions should the nurse include in the plan of care?

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Exhibits

Based on the client's status at 1400, the nurse should plan to do which of the following? Select all that apply.