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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.
Potential Actions

Set up supplemental oxygen delivery

Increase the fraction of inspired oxygen

Gather supplies for extubation

Place a nasogastric tube

Offer the client ice chips

Suggest a different ventilator mode to the provider

Set the ventilator to give mandatory breaths

Answer and Explanation

Correct Answer : A,C,E

A. Set up supplemental oxygen delivery - This could be necessary as the client is being weaned off the ventilator and may require additional oxygen support.
C. Gather supplies for extubation - As the client is being weaned off the ventilator and the pressure support has been decreased to 0 cm H2O, extubation may be imminent.
E. Offer the client ice chips - Once extubated, the client may have a dry mouth and throat from the intubation tube. Ice chips can help soothe the throat and keep the mouth moist.

B. Increase the fraction of inspired oxygen - This action is not indicated based on the information provided. The client’s oxygen saturation is within normal range and there’s no indication that the client is experiencing difficulty breathing or hypoxia.
D. Place a nasogastric tube - There’s no indication in the scenario that the client has a need for a nasogastric tube. This procedure is typically done for clients who have difficulty swallowing or need help with feeding, neither of which is mentioned in the scenario.
F. Suggest a different ventilator mode to the provider - The client is already being successfully weaned off the ventilator, as indicated by the decreasing pressure support. There’s no indication in the scenario that a different ventilator mode is needed.
G. Set the ventilator to give mandatory breaths - This action would be counterproductive to the weaning process. The client is already on a ventilator mode with no mandatory breaths and is being successfully weaned off the ventilator.

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Correct Answer is C

Explanation

Choice A rationale

While understanding risk factors for osteoporosis is important, it is not the highest priority for an older adult client diagnosed with osteoporosis. The highest priority is ensuring the client’s safety to prevent falls and fractures.

Choice B rationale

While constipation due to immobility can be a concern for clients with osteoporosis, it is not the highest priority for an older adult client diagnosed with osteoporosis. The highest priority is ensuring the client’s safety to prevent falls and fractures.

Choice C rationale

Identifying home safety hazards to be resolved immediately is the highest priority for an older adult client diagnosed with osteoporosis. Osteoporosis increases the risk of fractures, and falls are a common cause of fractures in older adults. Therefore, ensuring a safe environment is crucial.

Choice D rationale

While adding calcium-rich foods to the daily diet can help manage osteoporosis, it is not the highest priority for an older adult client diagnosed with osteoporosis. The highest priority is ensuring the client’s safety to prevent falls and fractures.

A. Change the surgical dressing promptly when it becomes soiled. B. Monitor for any increase in the white blood cell count. C. Educate the family on the importance of adhering to contact precautions. D. Always wear a face mask while performing wound care.

Correct Answer is A

Explanation

Choice A rationale

Changing the surgical dressing promptly when it becomes soiled is crucial to minimize the risk of a MRSA recurrence in the postoperative wound. A soiled dressing can become a medium for bacterial growth, including MRSA, and can potentially contaminate the wound.

Choice B rationale

Monitoring for any increase in the white blood cell count is important in detecting an infection, including a MRSA infection. However, it is not the most crucial intervention to minimize the risk of a MRSA recurrence in the postoperative wound.

Choice C rationale

Educating the family on the importance of adhering to contact precautions is important in preventing the spread of MRSA. However, it is not the most crucial intervention to minimize the risk of a MRSA recurrence in the postoperative wound.

Choice D rationale

Wearing a face mask while performing wound care can help prevent the spread of MRSA. However, it is not the most crucial intervention to minimize the risk of a MRSA recurrence in the postoperative wound.

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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. Potential Actions

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing a teaching plan for an older adult client diagnosed with osteoporosis.Which expected outcome has the highest priority for this client?

Correct Answer is C

Explanation

A nurse is caring for a patient who has undergone a small bowel resection and has a history of methicillin-resistant Staphylococcus aureus (MRSA). Which nursing intervention is most crucial to minimize the risk of a MRSA recurrence in the postoperative wound?

Correct Answer is A

Explanation

While taking vital signs, a critically ill male client grabs the nurse’s hand and asks the nurse not to leave.What is the most appropriate action for the nurse to take?

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?

A patient informs the nurse about starting an exercise program a month ago to lose weight and improve sleep.The patient states, “It still takes at least two hours to fall asleep at night.”. What action should the nurse take?

A client admitted with pneumonia and on bedrest has not had the strength to perform self-care.Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure injury?

An elderly patient with osteoarthritis is experiencing increased pain and stiffness in their right knee.What pathological condition should the nurse identify as the cause of these symptoms?

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.
Potential Actions