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Exhibits

The nurse notifies the healthcare provider of the client's status. The healthcare provider comes to the bedside to evaluate the client.

Which should the nurse do? Select all that apply.

Increase the fraction of inspired oxygen

Suggest a different ventilator mode to the provider

Offer the client ice chips

Set the ventilator to give mandatory breaths

Set up supplemental oxygen delivery

Gather supplies for extubation

Place a nasogastric tube

Answer and Explanation

Correct Answer : B,E,F

A.   Since the client is already on a fraction of inspired oxygen (FIO2) of 35% and has successfully weaned off the ventilator, increasing the FIO2 may not be necessary unless the client's oxygenation status deteriorates post-extubation.
B.   As the client has successfully weaned off pressure support and is now at 0 cm H2O, the healthcare provider may consider transitioning to a different ventilator mode such as T-piece or CPAP (Continuous Positive Airway Pressure) to further assess the client's ability to breathe spontaneously without ventilator support.
C.   Ice chips are typically offered to conscious patients to alleviate thirst or dry mouth. The client was previously intubated and may not be fully conscious or able to swallow safely immediately post- extubation.
D.   Since the client has been weaned off pressure support successfully, there is no indication to set the ventilator to provide mandatory breaths. The focus is on assessing the client's ability to breathe spontaneously.
E.   Even though the client has been weaned off the ventilator, it's important to ensure adequate oxygenation. Setting up supplemental oxygen delivery, such as via nasal cannula or face mask, can support the client's oxygen needs during the transition phase post-extubation.
F.   Since the client has been successfully weaned to 0 cm H2O pressure support and the healthcare provider is evaluating the client, gathering supplies for potential extubation is appropriate. This includes ensuring all necessary equipment and supplies for a safe extubation procedure are readily available at the bedside.
G.   Unless specifically indicated for other medical reasons not mentioned, there is no immediate need to place a nasogastric tube based on the information provided about the client's current condition post- weaning.

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Correct Answer is ["A","B","E","F"]

Explanation

A. Clonazepam is a benzodiazepine used primarily for anxiety disorders and can affect mental status, including cognition and level of alertness. Regular assessment helps monitor for any changes in mental status, such as drowsiness, confusion, or sedation, which are potential side effects of clonazepam.
B. This intervention helps maintain oral hygiene, which is important when a client is taking medications orally. Benzodiazepines like clonazepam can cause dry mouth as a side effect, which can contribute to oral hygiene issues such as increased risk of dental caries or oral infections.
C. Clonazepam itself does not directly affect calcium levels. Monitoring calcium levels is not a routine nursing intervention specifically related to clonazepam administration. This option is not appropriate in this context.
D. Clonazepam is not an opioid and does not directly interact with opioids in a way that would necessitate having an opioid agonist at the bedside. This option is not relevant for a client starting clonazepam.
E. Clonazepam can cause dizziness and impair coordination, especially when starting the medication or with dose changes. Assisting the client to the bathroom helps prevent falls and ensures safety, particularly if the client experiences dizziness or sedation.
F. Benzodiazepines like clonazepam can cause hypotension (low blood pressure), which may exacerbate upon standing (orthostatic hypotension). Screening involves checking blood pressure and heart rate in different positions (lying, sitting, standing) to detect orthostatic changes. This is important to prevent falls and other complications.

A. A female adolescent admitted with multiple genital Herpes simplex II lesions. B. Twin siblings admitted with scarlet fever that is complicated with pneumonia. C. An older client with scabies who is admitted from an extended care facility. D. A client with a positive Mantoux and sputum cultures results positive for acid-fast bacillus (AFB).

Correct Answer is D

Explanation

Rationale

A. Herpes simplex virus type II (HSV-II) primarily spreads through direct contact with the lesions and is not airborne. Airborne precautions and negative airflow rooms are not necessary for this condition.

B. Scarlet fever is caused by Group A Streptococcus bacteria and typically spreads through respiratory droplets. However, scarlet fever itself does not require airborne precautions. If complicated with pneumonia, respiratory droplets could potentially spread the infection, but specific airborne precautions are generally not required unless there are other pathogens involved that require it.

C. Scabies is caused by the Sarcoptes scabiei mite and spreads through direct skin-to-skin contact. It does not require airborne precautions or negative airflow rooms.

D. Apositive Mantoux test and sputum cultures positive for acid-fast bacillus (AFB) suggest tuberculosis (TB) infection. TB is spread through airborne droplets (e.g., coughing, sneezing), and therefore, requires airborne precautions including negative airflow rooms to prevent transmission to others.A

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Exhibits The nurse notifies the healthcare provider of the client's status. The healthcare provider comes to the bedside to evaluate the client. Which should the nurse do? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The nurse reviews the healthcare providers (HCP) prescription for clonazepam and gives the medication as prescribed. Which nursing intervention(s) is/are appropriate for the client starting clonazepam? Select all that apply.

Correct Answer is ["A","B","E","F"]

Explanation

The nurse is working on an infectious disease unit. Which client should be assigned to a room with negative airflow, while requiring personnel to use a particulate respirator mask, and requiring staff to observe airborne, as well as standard precautions?

Correct Answer is D

Explanation

When conducting diet teaching for a client who was diagnosed with hypertension, which food(s) should the nurse encourage the client to eat? Select all that apply.

The nurse is caring for a 3-year-old client who is two hours postoperative from a cardiac catheterization via the right femoral artery. Which assessment finding is an indication of arterial obstruction?

A client arrives to the emergency department with chest pain after taking sildenafil. Based on the client's history, which medication should the nurse withhold?

An unresponsive victim of a diving accident is brought to the emergency department where it is determined that immediate surgery is required to save the client's life. The client is accompanied by a close friend, but no family members are available. Which action should the nurse take first?

A client taking temazepam informs the nurse of plans to quit taking the medication due to feelings of "hungover" the next day. Which action should the nurse implement?

Exhibits

The nurse notifies the healthcare provider of the client's status. The healthcare provider comes to the bedside to evaluate the client.

Which should the nurse do? Select all that apply.