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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 C

Explanation

Rationale

A. In heart failure exacerbation, decreased cardiac output can lead to poor peripheral perfusion, potentially manifesting as weak or diminished pedal pulses. However, in the context of acute symptoms such as palpitations or chest discomfort, assessing the rhythm and rate of central pulses (like the apical pulse) may be more immediate and informative.

B. Capillary refill time assesses peripheral perfusion and can indicate circulatory status. Prolonged capillary refill (>2 seconds) may indicate poor perfusion, which could occur in heart failure exacerbation due to reduced cardiac output. It is a valuable assessment, but in this scenario, focusing on more central aspects such as the heart rhythm is typically more immediate.

C. Assessing the rhythm of the apical pulse is crucial in this scenario. The client's sensation of "flopping" in the chest suggests palpitations or irregular heartbeats, which could indicate arrhythmias such as atrial fibrillation or other dysrhythmias.

D. Skin elasticity primarily assesses hydration status and may provide information about overall skin integrity but is less directly related to the acute symptoms described by the client. While important in general assessments, it does not directly address the urgent need to assess for arrhythmias or irregular heartbeats.

A. Soft abdomen, absent bowel sounds, no bleeding on dressing. B. History of vomiting at home for 3 days prior to surgery. C. Peripheral pulses present with full range of motion of both legs. D. Declining to take ice chips despite reporting of dry mouth.

Correct Answer is D

Explanation

A. This information is crucial as it provides insight into the client's abdominal assessment post- laparotomy. A soft abdomen with absent bowel sounds suggests normal bowel function has not yet returned, which is common after abdominal surgery. However, this does not have immediate postoperative implications.

B. A history of vomiting prior to surgery could indicate a gastrointestinal issue that may impact the client’s recovery or increase the risk of complications such as nausea and vomiting postoperatively.However, this history may not immediately affect the current postoperative care as much as some other findings (such as changes in bowel sounds or bleeding) in the acute postoperative period.

C. This information provides reassurance regarding circulation and mobility of the lower extremities. However, it may not be as urgent to report immediately unless there were concerns during surgery or potential complications related to positioning or circulation.

D.This should be reported to ensure that the client is receiving proper hydration and that their hydration status is carefully monitored. It’s especially important to monitor for dehydration or difficulties with oral intake following surgery.

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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.

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Naxlex Comprehensive Predictor Exams

A client with a recent exacerbation of heart failure reports to the nurse feeling uncomfortable and anxious, with a sensation of the flopping in the chest. While waiting for an electrocardiogram (ECG), which assessment is most important for the nurse to obtain?

Correct Answer is C

Explanation

Correct Answer is D

Explanation

A client arrives at a hurricane disaster medical area seeking treatment for diarrhea. Which source of contamination should the nurse consider when interviewing the client about exposure?

Exhibits Select from the options to complete the sentence. After listening to the client's symptoms, the nurse realizes that she likely has dropdown related to dropdown

A client has developed atrial fibrillation with a ventricular rate of 150 beats/minute observed via telemetry. The client's blood pressure is 80/40 mm Hg. Which finding is most important for the nurse to report to the healthcare provider?

While caring for a client with a full thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

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.