Try Naxlex NCLEX-RN (Free-Trial)

Patient Data
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

Gather supplies for extubation

Set up supplemental oxygen delivery

Offer the client ice chips

Set the ventilator to give mandatory breaths

Suggest a different ventilator mode to the provider

Place a nasogastric tube

Answer and Explanation

Correct Answer : B,C,E

Rationale:
A. Increase the fraction of inspired oxygen: Increasing FiO₂ is only necessary if the client shows signs of hypoxemia or respiratory distress. Since oxygen saturation and respiratory status are not reported as compromised, this is not the immediate intervention.

B. Gather supplies for extubation: The client has been weaned to 0 cm H₂O pressure support, indicating readiness for spontaneous breathing. Preparing extubation supplies ensures the nurse is ready for safe removal of the endotracheal tube when the healthcare provider decides it is appropriate.

C. Set up supplemental oxygen delivery: After extubation, the client may require supplemental oxygen to maintain adequate oxygenation. Setting up oxygen delivery devices in advance promotes a smooth transition from mechanical ventilation to spontaneous breathing.

D. Offer the client ice chips: Ice chips are inappropriate for an intubated client or a client being evaluated for extubation, as swallowing may be impaired and aspiration risk is high. Oral intake should only be introduced after a swallow assessment.

E. Set the ventilator to give mandatory breaths: Providing mandatory breaths may be necessary if the client shows signs of respiratory fatigue or inadequate ventilation. This intervention supports the client temporarily until extubation is safely performed.

F. Suggest a different ventilator mode to the provider: While input may be valuable, the healthcare provider evaluates ventilator management and decides on mode adjustments. The nurse should focus on preparing for extubation and supporting spontaneous breathing.

G. Place a nasogastric tube: NG tube insertion is not indicated solely because the client is being weaned from the ventilator. This intervention is unrelated unless there are concerns about gastric distention or feeding tolerance post-extubation.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Rationale:
A. Monitor the client every 1 hour for changes in the GCS score: Frequent monitoring is important, but a sudden drop from 13 to 6 indicates significant neurological deterioration that requires immediate reporting rather than just continued observation.

B. Prepare the family for the client's imminent death: While family support is important, it is premature to focus on end-of-life discussions before stabilizing the client and notifying the healthcare provider of acute neurological decline.

C. Notify the healthcare provider of the GCS score: A GCS of 6 represents severe brain injury and indicates that the client may require urgent interventions, such as airway protection, imaging, or neurosurgical evaluation. Immediate notification of the healthcare provider is the priority action.

D. Begin cardiopulmonary resuscitation (CPR): CPR is indicated only if the client is pulseless or apneic. A GCS of 6 reflects decreased consciousness but does not necessarily indicate cardiopulmonary arrest, so CPR is not immediately warranted.

A. Apply compression stockings. B. Perform active range of motion exercises. C. Massage the extremities twice a week. D. Give antispasmodic medications.

Correct Answer is D

Explanation

Rationale:
A. Apply compression stockings: Compression stockings help prevent deep vein thrombosis in clients with limited mobility but do not address spasticity. While important for circulation, they are not effective for controlling involuntary muscle movements.

B. Perform active range of motion exercises: Range of motion exercises maintain joint flexibility and prevent contractures, but they do not sufficiently manage spasticity, which is caused by upper motor neuron injury and requires targeted intervention.

C. Massage the extremities twice a week: Massage may provide temporary relief or comfort but is insufficient to control the frequency or intensity of spastic muscle movements. Relying solely on massage would not adequately manage the condition.

D. Give antispasmodic medications: Antispasmodic agents, such as baclofen or tizanidine, reduce muscle tone and control spasticity by acting on the central nervous system. Administering these medications directly addresses involuntary muscle contractions and improves functional mobility and comfort.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Body system	Findings
Cardiovascular	Pedal pulse of 2+ or better Blood pressure of 120/74 mm Hg Capillary refill of 4 seconds in lower extremities
Neurovascular	Skin that is pale, cool to touch Pupils equal and nonresponsive to light Absence of numbness or tingling in feet
Renal Perfusion	Creatinine of 1.2 mg/dL (106 mmol/L) Client has urine output of 1,600 mL in 24 hours Decreased blood urea nitrogen (BUN) level of 9.8 mg/dL (3.50 mmol/L)

Patient Data 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

The nurse is completing a neurological assessment on a client with a closed head injury. The Glasgow Coma Scale (GCS) score was 13 on admission. It is now assessed at 6. Which is the priority nursing intervention based on the client's current GCS?

Correct Answer is C

Explanation

A client who sustained an L-1 spinal cord injury six months ago that resulted in paraplegia is now experiencing spastic muscle movements in the lower extremities. Which intervention should the nurse implement?

Correct Answer is D

Explanation

A client's telemetry monitor indicates ventricular fibrillation (VF). Which should the nurse do first?

Exhibits Which of the following findings should the nurse prioritize?

Patient Data Exhibits After two days of intensive care, the client is transferred to the telemetry floor. The floor nurse is preparing a plan of care for the client. Which modifiable risk factor(s) should the nurse include in the teaching for this client? Select all that apply.

While caring for a client with a cervical spine injury, which assessment finding should the nurse report to the healthcare provider immediately?

An unconscious client is demonstrating pulseless ventricular tachycardia (PVT).The nurse checks the client's pulse and begins cardiopulmonary resuscitation (CPR). The defibrillator and crash cart arrive at the bedside and the client is shocked. Which action should the nurse implement next?

Patient Data
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.