Which would be the most important action immediately following extubation of a patient?

Encourage patient to deep breathe and use incentive spirometer

Offer the patient medication for sedation

Assess patient's ability to speak

Assess vital signs and effort of breathing

Answer and Explanation

The Correct Answer is D

Choice A reason:

Encouraging the patient to deep breathe and use an incentive spirometer is important for lung expansion and preventing atelectasis. However, it is not the most immediate action following extubation.

Choice B reason:

Offering the patient medication for sedation is not appropriate immediately following extubation, as it could depress respiratory function and interfere with the patient's ability to clear secretions and maintain an open airway.

Choice C reason:

Assessing the patient's ability to speak is important to ensure that the vocal cords were not damaged during the intubation process. However, this is secondary to ensuring that the patient is breathing effectively and maintaining adequate oxygenation.

Choice D reason:

Assessing vital signs and effort of breathing is the most immediate and important action following extubation. Monitoring the patient’s respiratory status ensures that they are maintaining a patent airway, breathing effectively, and not experiencing respiratory distress or failure.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Choice A reason:

Decorticate posturing involves abnormal flexion of the arms towards the chest and extension of the legs. This posture indicates damage to the corticospinal tract at the level of the diencephalon. The described response does not match decorticate posturing.

Choice B reason:

Flexion withdrawal is a response to painful stimuli where the patient pulls away or flexes the affected limb. This is a less severe response than posturing and does not match the description provided in the scenario.

Choice C reason:

Localization of pain refers to the patient's ability to purposefully move a hand to the site of a painful stimulus, indicating higher brain function. The described response of arm and leg extension with pronation does not fit this description.

Choice D reason:

Decerebrate posturing is characterized by extension of the arms and legs, pronation of the arms, and plantar flexion. This posture indicates severe brainstem damage and is consistent with the described response.

A. Need for increased FiO2 administration. B. Increased inflation of the lungs. C. Prevention of alveolar collapse during expiration. D. Prevention of barotrauma to the lung tissue.

Correct Answer is C

Explanation

Choice A reason:

The application of PEEP does not inherently increase the need for FiO2 (fraction of inspired oxygen) administration. PEEP helps improve oxygenation, potentially reducing the need for higher FiO2 levels.

Choice B reason:

While PEEP can contribute to better lung inflation by keeping the alveoli open, this is a secondary effect. The primary goal of PEEP is to prevent alveolar collapse at the end of expiration.

Choice C reason:

PEEP prevents alveolar collapse during expiration, which is its primary therapeutic effect. By maintaining a certain level of pressure in the lungs at the end of expiration, PEEP ensures that the alveoli remain open, improving gas exchange and oxygenation.

Choice D reason:

Although PEEP can help reduce the risk of atelectasis (collapse of part or all of a lung), it does not directly prevent barotrauma. Barotrauma is related to high airway pressures, and careful monitoring of ventilator settings is necessary to avoid it.

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

Which would be the most important action immediately following extubation of a patient?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse applies a painful stimulus to the nailbeds of an unconscious patient. The patient responds with extension of the arms and legs, pronation of the arms, and plantar flexion. The nurse documents this as:

Correct Answer is D

Explanation

When planning care for a patient on a mechanical ventilator, the nurse understands that the application of positive end-expiratory pressure (PEEP) to the ventilator settings has which therapeutic effect?

Correct Answer is C

Explanation

A nurse is caring for a patient who has a closed-head injury with ICP readings ranging from 16-22 mm Hg. What actions should the nurse take to decrease the potential for raising the client's ICP? Select all that apply.

After brain death has been determined, which of the following is a priority nursing action in caring for an organ donor?

During routine suctioning of a client with an endotracheal tube, the patient becomes diaphoretic and nauseous, and the heart rate decreases to 39 beats/min. What is the nurse's best action at this time?

The nurse is assessing a patient with suspected traumatic cervical spine injury who just arrived to the emergency department. The nurse knows the priority actions for caring for this patient include all of the following. Place the actions in order of priority.

The nurse receives new orders for multiple clients. Which order should be the nurse's priority?

A nurse is caring for a patient with a head injury who has developed diabetes insipidus and is receiving desmopressin. The nurse understands the therapeutic outcome is a decrease in:

A nurse is caring for four patients in the neurologic intensive care unit. After receiving the hand-off report, which patient does the nurse see first?

A patient is brought to the emergency department after sustaining injuries in a severe car crash. The patient's chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the patient is cyanotic. What action by the nurse is the priority?