The nurse is caring for a client with hypercapnic respiratory failure. The client is lethargic & slow to follow commands. Current vitals: BP 78/52. pulse 132. respirations 8, and pulse ox 84% on 35% Venturi mask. The nurse would anticipate which medical prescription?

Insertion of a tracheostomy to maintain the airway

Use of noninvasive positive pressure ventilation (BIPAP)

Endotracheal intubation with mechanical ventilation

Administration of 50% Venturi mask

Answer and Explanation

The Correct Answer is B

A. Insertion of a tracheostomy to maintain the airway: This is not the first step in the management of hypercapnic respiratory failure. A tracheostomy is usually considered in cases where prolonged mechanical ventilation is required or for patients who need long-term airway support. It would not be immediately prescribed in this situation.

B. Use of noninvasive positive pressure ventilation (BIPAP): The client is showing signs of hypercapnic respiratory failure, indicated by lethargy, slow response to commands, and low oxygen saturation (pulse ox 84%) despite receiving oxygen via a Venturi mask. BIPAP (Bilevel Positive Airway Pressure) is a form of noninvasive ventilation that can help improve both oxygenation and ventilation by providing positive pressure to help the client breathe more effectively. It is often used in cases of hypercapnic respiratory failure, especially when the patient is alert enough to tolerate the mask.

C. Endotracheal intubation with mechanical ventilation: While this may be necessary if noninvasive ventilation (like BIPAP) is not effective, endotracheal intubation is typically considered when the patient is unable to tolerate noninvasive ventilation or if their respiratory failure worsens significantly. Given that the patient is still responsive (though lethargic), BIPAP would likely be tried first.

D. Administration of 50% Venturi mask: Increasing the oxygen concentration is unlikely to resolve the underlying issue of hypercapnia (elevated CO2 levels) in this patient. Hypercapnic respiratory failure is primarily due to inadequate ventilation, not just oxygen deficiency. Therefore, a higher concentration of oxygen may not be sufficient and would not address the need for improved ventilation.

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

A. The client will be turned every 2 hours is a general nursing care practice for all immobile clients to prevent pressure injuries, but it is not specific to the protocol surrounding the use of restraints.

B. The client will need to be monitored every one-half hour is incorrect because clients in restraints must be monitored more frequently—typically every 15 minutes, depending on facility policy and client condition, to assess circulation, skin integrity, and psychological well-being.

C. Documentation of the event will include interventions attempted prior to initiating restraints is the correct answer. Before applying restraints, it is a legal and ethical requirement to document all less restrictive interventions that were attempted and found ineffective. This ensures that restraints are used only as a last resort and that the client's rights and safety are protected.

D. The physician must be present at the time of the restraint episode is incorrect. While a physician's order is required for restraint use, the physician does not need to be physically present at the time of application. However, the physician must conduct a face-to-face evaluation within a specific timeframe, usually within 1 hour of the restraint being applied, depending on regulatory guidelines.

A. Teach the importance of hot showers to help relax. B. Have the patient prioritize activities early in the day. C. Schedule activities late in day and in the evening. D. Provide supplemental oxygen when fatigued.

Correct Answer is B

Explanation

A. Teach the importance of hot showers to help relax: While hot showers may help some people relax, they can also increase fatigue or exacerbate symptoms in conditions like MS or MG. Heat intolerance is a common symptom of MS, and in MG, fatigue can be worsened by hot environments. Therefore, hot showers may not be advisable for these patients.

B. Have the patient prioritize activities early in the day: Fatigue is a hallmark symptom in both Multiple Sclerosis (MS) and Myasthenia Gravis (MG), and patients often experience more energy in the morning. For this reason, it's crucial to schedule the most important and energy-demanding activities early in the day when the patient has more strength and stamina. This helps conserve energy throughout the day and manage fatigue more effectively.

C. Schedule activities late in day and in the evening: Fatigue typically worsens as the day goes on for patients with MS or MG, so scheduling activities later in the day when the patient’s energy levels are lower can worsen the fatigue and make it harder to complete tasks.

D. Provide supplemental oxygen when fatigued: Providing supplemental oxygen is generally reserved for patients who are experiencing hypoxemia or respiratory distress. Fatigue in MS or MG is usually not related to oxygen deficiency, so supplemental oxygen is not an appropriate intervention for general fatigue in these conditions.

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

The nurse is caring for a client with hypercapnic respiratory failure. The client is lethargic & slow to follow commands. Current vitals: BP 78/52. pulse 132. respirations 8, and pulse ox 84% on 35% Venturi mask. The nurse would anticipate which medical prescription?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When placing an agitated client in restraints, the nurse understands that which of the following must occur?

Correct Answer is C

Explanation

The nurse is caring for a patient waiting for proper diagnosis with Multiple Sclerosis (MS) or Myasthenia Gravis (MG). The patient is reporting severe fatigue. Which priority intervention would the nurse implement to address this issue for either diagnosis?

Correct Answer is B

Explanation

The nurse is to begin a nitroglycerin infusion for a client diagnosed with an anterior wall myocardial infarction. Which assessment finding should the nurse report to the physician immediately?

To achieve the outcome of fall prevention at home in the patient diagnosed with Parkinson's Disease (PD), which intervention would the nurse include in the plan of care?

What key feature should the nurse be aware of when ventilating clients with acute respiratory distress syndrome (ARDS)?

The nurse caring for a critically ill client would suspect the development of acute respiratory distress syndrome (ARDS) in which of the following situations? The client with:

The nurse is caring for a patient that has had an acute myocardial infarction. What goals should the nurse use to guide this patient's care? (SELECT ALL THAT APPLY).

The nurse is caring for a patient diagnosed with Multiple Sclerosis (MS) who is complaining of diplopia. Which intervention would be appropriate for the patient with this problem?

The client is prescribed pantoprazole 8 mg/hr after a bolus dose is given. The standard concentration from the pharmacy is 80 mg in 200 mL. How many hours will one bag take to infuse? (Use a leading zero if it applies. Do not use a trailing zero. Round to the nearest hour.)

The nurse is caring for a client receiving mechanical ventilation. The nurse hears the low-pressure alarm sound. After checking the client and ventilator, the nurse cannot determine the source of the alarm. What should the nurse do next?