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.

Set up supplemental oxygen delivery

Suggest a different ventilator mode to the provider

Place a nasogastric tube

Increase the fraction of inspired oxygen

Set the ventilator to give mandatory breaths

Gather supplies for extubation

Answer and Explanation

Correct Answer : A,F

A. After successful weaning, the client will need supplemental oxygen via nasal cannula or face mask to ensure continued oxygenation post-extubation.

B. The current weaning process is progressing as expected with pressure support decreasing steadily. There is no indication that a different ventilator mode is necessary at this time.

C. There is no indication in the scenario that the client requires a nasogastric tube for ventilation weaning or extubation.

D. The fraction of inspired oxygen (FiO₂) is currently at 35%, which is appropriate during the weaning process. Increasing FiO₂ without indication could disrupt the weaning progression.

E. The weaning process is designed to gradually reduce support. Adding mandatory breaths would counteract the progress made in reducing ventilatory support.

F. The client has been weaned to minimal ventilatory support, which suggests the healthcare provider may plan for extubation. Having supplies ready will facilitate a smooth extubation process.

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Correct Answer is ["C","D","E","F","G"]

Explanation

A. Blood pressure of 136/90 mm Hg while slightly elevated, is not unusual for someone in pain or distress and does not require immediate investigation.

B. Oxygen saturation 95% on room air is within the acceptable range for an adult and does not indicate immediate respiratory compromise.

C. The misalignment of the collarbone indicates a possible fracture or dislocation, which requires further assessment and imaging to confirm the extent of the injury.

D. A cool left arm could indicate compromised blood flow, possibly due to vascular injury from the trauma. This requires immediate investigation to prevent complications such as ischemia.

E. Swelling is a sign of trauma, which may indicate soft tissue damage, fractures, or inflammation. The nurse should monitor for further signs of internal bleeding or worsening injury.

F. Nausea and fatigue reported by client could suggest underlying issues such as a head injury, shock, or a systemic response to the trauma. Further evaluation is required to rule out serious complications like a concussion or other medical conditions.

G. Severe pain is a critical finding that needs prompt management. Pain assessment will guide the appropriate interventions, such as pain relief and further diagnostics to identify underlying causes.

H. While decreased range of motion is important, it is expected due to the trauma and pain from the fall. It will likely be addressed after the immediate concerns of injury and vascular status are managed.

A. Assign the newly hired UAP to clients who require the least complex level of care. B. Review the UAP's skills checklist and experience with the person who hired the UAP. C. Ask the most experienced UAP on the team to partner with the newly hired UAP. D. Evaluate the newly hired UAP's level of competency by observing the UAP deliver care.

Correct Answer is D

Explanation

A. Assigning the UAP to less complex clients may not adequately assess their competencies.

B. Reviewing documentation provides useful background information, but it does not verify actual competency in performing tasks. Direct observation is necessary.

C. While pairing with an experienced UAP may provide guidance, it does not replace the nurse’s responsibility to assess competency and ensure safe care.

D. The nurse is responsible for ensuring that all team members provide safe and appropriate care. Before assigning tasks, the nurse should assess the newly hired UAP’s competency by directly observing them perform client care. This helps determine their skill level and ensures client safety.

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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

Exhibits The nurse considers the brief interaction with the client and the triage report. What finding(s) should the nurse investigate further? Select all that apply.

Correct Answer is ["C","D","E","F","G"]

Explanation

A newly hired unlicensed assistive personnel (UAP) is assigned to a home healthcare team along with two experienced UAPs. Which intervention should the home health nurse implement to ensure adequate care for all clients?

Correct Answer is D

Explanation

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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.

A 4-month-old infant is brought to the clinic by a parent with symptoms of a runny nose, a slight fever and cough for the last two days. Which finding should alert the nurse that the child is in acute respiratory distress?

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.