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.

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Correct Answer is D

Explanation

Choice A reason:

While preparing the gastrointestinal tract for enteral feedings is important, it is not the primary reason for administering famotidine. Famotidine is typically used to reduce gastric acid production, not to prepare the GI tract for feedings.

Choice B reason:

Increasing the motility of the gastrointestinal tract is not the primary function of famotidine. Famotidine is an H2 receptor antagonist that works by decreasing the production of stomach acid.

Choice C reason:

Keeping the gastrointestinal tract functioning normally is a broad statement and does not specifically address the reason for administering famotidine. The drug's role in preventing stress ulcers is more relevant to the patient's current condition.

Choice D reason:

Famotidine is used to prevent stress ulcers, which can occur in critically ill patients, including those on mechanical ventilation. The stress of illness and mechanical ventilation increases the risk of developing gastric ulcers, and famotidine helps reduce this risk by decreasing gastric acid secretion.

A. The patient is coughing B. The ETT has a cuff leak C. The ventilator tubing has become disconnected D. The patient is complaining of a headache 8/10 pain

Correct Answer is A

Explanation

Choice A reason:

The patient coughing is the most likely cause of the high pressure alarm on a mechanical ventilator. Coughing can increase airway resistance and pressure, triggering the alarm. This is a common occurrence and should be addressed by assessing the patient's need for suctioning or other interventions to relieve the cough.

Choice B reason:

An endotracheal tube (ETT) cuff leak would typically cause a low pressure alarm, not a high pressure alarm. A cuff leak results in a loss of pressure within the ventilator circuit, leading to insufficient ventilation and a different alarm response.

Choice C reason:

If the ventilator tubing becomes disconnected, it would result in a low pressure alarm due to the loss of circuit integrity. A disconnection is a serious issue that needs immediate correction but does not cause high pressure alarms.

Choice D reason:

The patient's complaint of a headache does not directly relate to a high pressure alarm on the ventilator. While patient discomfort should always be addressed, it is not the most likely cause of the alarm in this scenario.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client is on mechanical ventilation and the client's spouse wonders why famotidine is needed since the client "only has lung problems." What response by the nurse is best?

Correct Answer is D

Explanation

The nurse is caring for a patient who is on mechanical ventilation and the high pressure alarm is sounding. Which of the following is the most likely cause?

Correct Answer is A

Explanation

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

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