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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 B

Explanation

A. Initiating teaching for client care after discharge is incorrect. Teaching, especially initial or comprehensive education, is within the scope of practice of a registered nurse (RN), not a practical nurse (PN).
B. Using bladder ultrasound to detect urinary retention is correct. This is a task within the scope of practice for a PN, as it involves data collection and does not require independent clinical judgment.
C. Completing comprehensive assessments is incorrect. Comprehensive assessments require critical thinking and are the responsibility of the RN. PNs may collect data but do not perform initial comprehensive assessments.
D. Beginning initial sterile wound care for surgical clients is incorrect. The RN should perform the first sterile dressing change postoperatively to assess the wound properly. The PN may perform subsequent dressing changes per facility policy.

A. A Repeated requests for attention from the nurse. B. B Periodic sighing and shaking the head. C. C Argumentativeness and use of profanity. D. D Decreased activity level and change in affect.

Correct Answer is C

Explanation

A. While repeated requests for attention from the nurse might indicate distress, they are not necessarily indicative of potential aggression or disruptive behavior.
B. Periodic sighing and shaking the head could suggest the client's emotional state, but they are not as indicative of potential aggression or disruptive behavior as argumentativeness and profanity.
C. Monitoring for argumentativeness and the use of profanity is crucial as they can escalate into disruptive or potentially aggressive behavior. It's important to assess the client's agitation level and ensure the safety of both the client and others on the mental health unit.

D. Decreased activity level and a change in affect may suggest a worsening of the client's mental state but are not immediate concerns in terms of safety on the unit.

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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

After receiving a change of shift report for clients on a medical surgical unit, which task should the nurse assign to the practical nurse (PN)?

Correct Answer is B

Explanation

A client on the mental health unit has been scowling and rapidly pacing up and down the hall for several minutes. Which behaviors are most important for the nurse to monitor?

Correct Answer is C

Explanation

The nurse identifies an electrolyte imbalance, an elevated blood pressure, and a weight gain of 4.4 lbs (2 kg) in 24 hours for a client with hepatic failure. Which intervention should the nurse include in the plan of care?

The nurse is caring for a client with heart failure. Which of these prescribed medications places the client at risk for cardiogenic shock?

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Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Exhibits

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