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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. Demonstrating how to palpate the popliteal pulse is not a suitable alternative for measuring blood pressure when the client cannot be measured in the arms or legs. Palpating peripheral pulses does not provide accurate blood pressure measurements.

B. Advising the UAP to document the last blood pressure obtained is insufficient because it does not address the need for current blood pressure monitoring. Documentation of past
measurements does not provide real-time information about the client's hemodynamic status.

C. Estimating the blood pressure by assessing the pulse volume of the client's radial pulses is a reasonable alternative when traditional blood pressure measurement sites are inaccessible. Although not as accurate as traditional methods, assessing the strength of peripheral pulses can provide valuable information about perfusion and blood pressure status.

D. Documenting why the blood pressure cannot be accurately measured is important for record- keeping but does not address the need for ongoing blood pressure monitoring or provide an alternative method for assessment.

A. Self-care deficit relative to motor disturbance. B. Risk for aspiration relative to muscle weakness. C. Risk for constipation relative to immobility. D. Impaired physical mobility relative to muscle rigidity.

Correct Answer is B

Explanation

A. Self-care deficit relative to motor disturbance. While self-care deficit is a concern for clients with Parkinson's disease due to motor disturbances, the highest priority is addressing the risk for aspiration to prevent potential life-threatening complications such as aspiration pneumonia.
B. Risk for aspiration relative to muscle weakness. Parkinson's disease can cause muscle weakness and impaired swallowing function, leading to an increased risk of aspiration.
Aspiration pneumonia is a severe complication that requires immediate attention, making this the highest priority nursing problem.
C. Risk for constipation relative to immobility. Constipation is a common problem in Parkinson's disease due to immobility and medication side effects. While constipation should be addressed, it is not as immediately life-threatening as the risk for aspiration.
D. Impaired physical mobility relative to muscle rigidity. Impaired physical mobility is a significant concern in Parkinson's disease, but muscle rigidity does not necessarily pose an
immediate risk of aspiration. Addressing impaired mobility is important for maintaining overall function and quality of life but may not be the highest priority in this scenario.

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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.

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Naxlex Comprehensive Predictor Exams

The unlicensed assistive personnel (UAP) reports that a client's blood pressure cannot be measured in the arms because the client has casts on both arms and is unable to be measured in the legs because the client is in the supine position. Which action should the nurse implement?

Correct Answer is C

Explanation

In formulating the nursing care plan for a client diagnosed with Parkinson's disease, which nursing problem has the highest priority?

Correct Answer is B

Explanation

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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.