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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

Explanation

Rationale

A. Monitoring intake and output closely is essential to assess fluid balance and ensure adequate hydration. Replacing fluids intravenously based on this assessment helps maintain hemodynamic stability and prevent dehydration, electrolyte imbalances, and hypovolemia.

B. After surgery for fistula repair, it is important to monitor wound drainage to assess for complications such as infection or delayed healing. Excessive drainage may indicate issues with wound healing or ongoing inflammation, requiring timely intervention.

C. Turning the client every 2 hours helps prevent complications such as pressure ulcers and respiratory complications. It promotes circulation, prevents skin breakdown, and aids in lung expansion. However, while important, this intervention is more focused on preventing physical complications rather than directly addressing the client's immediate medical needs post-surgery.

D. Clients with inflammatory bowel disease, especially those undergoing surgery and critically ill, are at increased risk for skin breakdown due to factors such as decreased mobility, medication effects, and overall health status. Regular skin assessments help detect early signs of breakdown and allow for prompt intervention to prevent pressure ulcers or skin complications.

A. Diarrhea and flatulence. B. Muscle pain. C. Abdominal cramps. D. Altered taste.

Correct Answer is B

Explanation

Rationale

A. Diarrhea and flatulence are common gastrointestinal side effects of statin medications like lovastatin. While uncomfortable for the client, these symptoms are typically not serious and do not require immediate follow-up unless severe or persistent.

B. Muscle pain, also known as myalgia, is a potential side effect of statin therapy. In some cases, statins can cause muscle inflammation (myositis) or more severe muscle breakdown (rhabdomyolysis), which can lead to serious complications such as kidney damage. If a client reports new or worsening muscle pain, especially if accompanied by weakness, tenderness, or dark urine, it requires immediate follow-up to assess for these potential complications.

C. Abdominal cramps can occur as a gastrointestinal side effect of statins but are generally not considered a serious adverse reaction. They may improve with time or adjustments in diet or medication administration timing.

D. Altered taste, such as a metallic taste, is a less common side effect of statin therapy. While it can be bothersome, it is usually not serious and does not typically require immediate follow-up unless severe or persistent.

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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

A client with a history of inflammatory bowel disease develops severe ulcerative colitis and is admitted to the intensive care unit after surgery for a fistula repair. Which intervention is most important for the nurse to include in the plan of care?

Correct Answer is A

Explanation

Which problem reported by a client taking lovastatin requires the most immediate follow-up by the nurse?

Correct Answer is B

Explanation

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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.