The nurse is managing 4 clients in the intensive care unit who are mechanically ventilated.

After performing a quick visual assessment, the nurse should prioritize care for the client who is exhibiting which finding.

An audible voice when client is trying to communicate.

Diminished breath sounds In the right posterior base.

Restrained and restless with a low volume alarm sounding.

High pressure alarm sounds when client is coughing.

Answer and Explanation

The Correct Answer is C

A)   Incorrect- an audible voice when client is trying to communicate, indicates that the client has some air passing through the vocal cords, which may be due to a partially deflated cuff or a speaking valve. This is not a life-threatening situation, but the nurse should ensure that the cuff pressure is adequate and that the client is not experiencing any discomfort or aspiration risk.
B)   Incorrect- This may indicate atelectasis, pneumonia, or pleural effusion in that lung area. The nurse should auscultate the client's lungs more thoroughly, monitor the client's oxygenation and ventilation parameters, and report the findings to the provider.
C)   Correct- This finding suggests that the client may have a ventilator disconnect, a leak in the circuit, or a cuff leak, which can compromise the client's oxygenation and ventilation. The nurse should immediately check the ventilator connections and tubing, and assess the client's vital signs and oxygen saturation.
D)   Incorrect- high-pressure alarm sounds when the client is coughing, which is a common occurrence in mechanically ventilated clients who have increased airway resistance due to secretions, bronchospasm, or coughing. The nurse should suction the client as needed, administer bronchodilators if prescribed, and ensure that the ventilator settings are appropriate for the client's condition.

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Correct Answer is A

Explanation

A) Correct - Acute dystonic reactions are involuntary muscle spasms caused by certain medications, including antipsychotic drugs. These reactions can sometimes affect the muscles of the face and neck, including the larynx. Benztropine is an anticholinergic medication commonly used to treat acute dystonic reactions. It works by blocking certain neurotransmitters that contribute to muscle spasms, helping to relieve the symptoms.

B) Incorrect - Divalproex is an anticonvulsant medication primarily used to treat epilepsy and bipolar disorder. It is not the appropriate treatment for acute dystonic reactions. These reactions are usually caused by certain antipsychotic medications and are characterized by sudden and involuntary muscle contractions. Divalproex does not have the specific mechanism of action needed to alleviate the symptoms of acute dystonic reactions.
C) Incorrect - Isotonic crystalloid fluids are used for various purposes, such as fluid resuscitation, maintaining hydration, and balancing electrolytes. However, they are not a treatment for acute dystonic reactions. These reactions are neurological and musculoskeletal in nature and require medications with specific anticholinergic properties, like benztropine, to address the underlying issue.
D) Incorrect - Lorazepam is a benzodiazepine commonly used for anxiety, sedation, and seizure control. While it can have a relaxing effect on muscles, it is not the first-line treatment for acute dystonic reactions. Anticholinergic medications like benztropine are more appropriate because they directly counteract the neurotransmitter imbalances that lead to muscle spasms in these reactions.

A. A 12-year-old child with history of asthma who is wheezing and complaining of shortness of breath. B. A 7-year-old child who has type 1 diabetes mellitus and is experiencing extreme hunger and shakiness. C. A 10-year-old child with bleeding lacerations on both knees after falling on the playground. D. A 5-year-old child who is crying uncontrollably because of an incontinent bowel episode.

Correct Answer is A,B,C,D

Explanation

This client has the highest priority, as he or she may be experiencing an acute asthma attack that can compromise the airway and oxygenation. The PN should assess the client's respiratory status, administer bronchodilators, and monitor for improvement or deterioration.

B. A 7-year-old child who has type 1 diabetes mellitus and is experiencing extreme hunger and shakiness.

This client has the second highest priority, as he or she may be experiencing hypoglycemia, which is a low blood glucose level that can cause neurologic symptoms such as confusion, seizures, or coma. The PN should check the client's blood glucose level, provide a source of glucose, and monitor for recovery or complications.

C. A 10-year-old child with bleeding lacerations on both knees after falling on the playground.

This client has the third highest priority, as he or she may have a risk of infection or blood loss from the wounds. The PN should clean and dress the lacerations, apply pressure if needed, and check for signs of infection or inﬂammation.

D. A 5-year-old child who is crying uncontrollably because of an incontinent bowel episode.

This client has the lowest priority, as he or she does not have a life-threatening or urgent condition, but a psychosocial or emotional issue. The PN should provide comfort and reassurance to the child, change his or her clothes, and explore the possible causes of the incontinence.

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The nurse is managing 4 clients in the intensive care unit who are mechanically ventilated. After performing a quick visual assessment, the nurse should prioritize care for the client who is exhibiting which finding.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client experiencing an acute dystonic reaction presents with a laryngeal spasm. Which treatment should the nurse prepare?

Correct Answer is A

Explanation

Correct Answer is A,B,C,D

Explanation

Prior to an invasive examination of a hospitalized client, a consent form should be obtained. Which action best describes the responsibility of the practical nurse (PN)?

Before leaving the room of a confused client, the nurse notes that a half-bow knot was used to attach the client's wrist restraints to the movable portion of the client's bed frame. What action should the nurse take before leaving the room?

Which statement by a mature adult client with advanced prostate cancer best indicates that he has reached a level of acceptance of his prognosis?

The healthcare provider prescribed octreotide 150 mcg/day subcutaneously for a client with dumping syndrome. The medication is available in 0.2 mg/mL vials. How many mL should the practical nurse (PN) administer? (Enter numerical value only. If rounding is required, round to the nearest hundredth).

The nurse identifies an electrolyte imbalance, elevated blood pressure, and exhibited changes in mental status for a client with chronic kidney disease. Which is the most important action for the nurse to take?

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While changing the dressing of a client who is immobile, the nurse notices the boundary of the wound has increased. Given there is a positive methicillin-resistant Staphylococcus aureus (MRSA), which is the most important action for the nurse to take?

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The nurse is managing 4 clients in the intensive care unit who are mechanically ventilated.

After performing a quick visual assessment, the nurse should prioritize care for the client who is exhibiting which finding.