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Patient Data

Exhibits

What actions can the nurse do to assist the client in improving their ventilation and oxygenation? Select all that apply.

Avoid treating fever with antipyretics

Encourage the client to take breaks from the oxygen mask every few hours

Providing suctioning so the client does not have to cough

Assist the client in ambulating safely

Asking the client do quick, shallow breaths

Positioning the client with the head of the bed elevated

Teaching the client to cough at least once an hour

Answer and Explanation

Correct Answer : B,D,F

B. Encourage the client to take breaks from the oxygen mask every few hours: While supplemental oxygen may be necessary for clients with pneumonia who are hypoxemic, encouraging periodic breaks from the oxygen mask allows the client to mobilize and promote lung expansion, which can improve ventilation and oxygenation.

D. Ambulation helps prevent complications such as pneumonia-associated atelectasis by promoting lung expansion and mobilizing respiratory secretions. However, it's essential to ensure that ambulation is safe and appropriate based on the client's condition and mobility status.

F. Elevating the head of the bed promotes optimal lung expansion, reduces the work of breathing, and helps improve oxygenation in clients with pneumonia. This position also facilitates drainage of respiratory secretions and decreases the risk of aspiration.

A. Fever is often a sign of infection and can increase metabolic demand and oxygen consumption. Treating fever with antipyretics helps reduce metabolic demand, discomfort, and respiratory distress, thereby potentially improving ventilation and oxygenation.

C. Suctioning may be necessary to remove respiratory secretions in clients with pneumonia who are unable to clear their airways effectively. However, routine suctioning should be avoided unless clinically indicated, as it may cause discomfort and irritation to the airways.

E. Quick, shallow breaths (hyperventilation) can lead to respiratory alkalosis and impair oxygenation. Instead, clients with pneumonia should be encouraged to breathe slowly and deeply to promote effective gas exchange and lung expansion.

G. Teaching the client to cough at least once an hour: While coughing can help clear respiratory secretions and improve ventilation in clients with pneumonia, coughing excessively or unnecessarily may cause fatigue and discomfort. Clients should be encouraged to cough as needed to clear secretions but not excessively.

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Correct Answer is A

Explanation

A. A corneal abrasion is a condition that may be exacerbated by the use of ketorolac due to its potential to delay healing and increase bleeding risks. Therefore, it is essential to ensure that a patient does not have a corneal abrasion before administering ophthalmic ketorolac.

B. Radiation exposure is not directly relevant to the administration of ophthalmic ketorolac.

C. The presence of a foreign body is not directly related to ketorolac use

D. The presence of a chemical burn is not related with ketorolac use in a client.

Correct Answer is ["38"]

Explanation

Drop rate (gtt/min) = Volume to be infused (mL)/ Time of infusion (minutes) × Drop factor (gtt/mL)

Given:

Volume to be infused (V) = 75 mL Time of infusion (T) = 30 minutes Drop factor = 15 gtt/mL
Using the formula:

Drop rate (gtt/min)= [75/30]*15 Drop rate (gtt/min)=2.5×15

Drop rate (gtt/min)=37.5
Rounding to the nearest whole number, the nurse should regulate the IV to deliver approximately 38 gtt/minute.

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Patient Data Exhibits What actions can the nurse do to assist the client in improving their ventilation and oxygenation? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receives a prescription for ophthalmic ketorolac, Prior to administering the medication, the nurse should review the medical record for which condition?

Correct Answer is A

Explanation

The healthcare provider prescribes an IV solution of clindamycin 850 mg in 75 mL of DW to infuse over 30 minutes. The drop factor is 15 gtt/mL. The nurse should regulate the IV to deliver how many glt/minute? (Enler numeric value only. If rounding is required, round to the nearest whole number.)

Correct Answer is ["38"]

Explanation

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A client who is experiencing respiratory distress is admitted with respiratory acidosis. Which pathophysiological process supports the client's respiratory acidosis?

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When performing postural drainage on a client with chronic obstructive pulmonary disease (COPD), which approach should the nurse use?

The client with Clostridium difficile in the stool receives a prescription for vancomycin PO. Which action should the nurse take before administering the first dose?

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Patient Data

Exhibits

What actions can the nurse do to assist the client in improving their ventilation and oxygenation? Select all that apply.