The client's low volume alarm on the ventilator begins to alarm after the x-ray technicians completed the routine chest x-ray. The primary nurse walks in and troubleshoots the alarm by doing which of the following? (Select all that apply.)

Assess strict urinary output on the foley catheter

Increase the positive-end expiratory pressure on the ventilator

Check endotracheal tube placement at the teeth or lip

Assess for a cuff leak on the endotracheal tube

Secure all connections from the client to the ventilator

Answer and Explanation

Correct Answer : C,D,E

A. Urinary output assessment is unrelated to ventilator low volume alarms.

B. Increasing PEEP is not a first-line action for low volume alarms and may worsen patient status if cause is not identified.

C. Checking endotracheal tube placement ensures the tube hasn't moved or become dislodged during the x-ray.

D. Assessing for a cuff leak is important because a leak can cause low tidal volumes and trigger alarms.

E. Securing all ventilator connections prevents air leaks and ensures proper ventilation.Top of FormBottom of Form

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Correct Answer is D

Explanation

A. Brudzinski's sign is when flexion of the neck causes involuntary flexion of the hips and knees—this is a different physical response.
B. Nuchal rigidity refers to neck stiffness and is a general sign of meningeal irritation, not specific to leg extension.
C. Bradykinesia refers to slowness of movement, typically seen in Parkinson’s disease, not meningitis.
D. Kernig's sign is positive when the client experiences pain or resistance upon extending the leg at the knee from a flexed hip and knee position, indicating meningeal irritation as seen in meningitis.

A. Initiate fluid resuscitation. B. Insert an indwelling urinary catheter. C. Medicate for pain. D. Maintain the airway.

Correct Answer is D

Explanation

A. Initiating fluid resuscitation is a vital component of burn management during the resuscitation phase, but it follows airway stabilization in priority.
B. Inserting an indwelling urinary catheter is important for monitoring fluid output and kidney function, but it is not the immediate priority.
C. Pain management is essential in burn care, but it is not the most urgent intervention during the initial phase of care.
D. According to the ABCs of emergency care (Airway, Breathing, Circulation), securing the airway is always the first priority, especially in clients with burns to the chest and upper body where airway edema and inhalation injury are likely.

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The client's low volume alarm on the ventilator begins to alarm after the x-ray technicians completed the routine chest x-ray. The primary nurse walks in and troubleshoots the alarm by doing which of the following? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has meningitis and notes that the client experiences pain with extension of their leg from a flexed positions. Which of the following conditions is the client displaying?

Correct Answer is D

Explanation

A nurse in an emergency department is caring for a client who has deep partial- and full-thickness burns to his chest, abdomen, and upper arms. What is the nurse's priority intervention for this client during the resuscitation of phase of injury?

Correct Answer is D

Explanation

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A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take. Use all the steps.)

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The client's low volume alarm on the ventilator begins to alarm after the x-ray technicians completed the routine chest x-ray. The primary nurse walks in and troubleshoots the alarm by doing which of the following? (Select all that apply.)

A nurse is caring for a client who who has had a stroke involving the right hemisphere. Which of the following alterations in function should the nurse expect?