A 44-year-old female patient has been admitted for an abdominal abscess and sepsis.
She has been on mechanical ventilatory support for the last 2 weeks and is due to start ventilator weaning today.
She is currently on pressure support of 25 cm water (H2O) with no mandatory breaths and a fraction of inspired oxygen (FiO2) of 35%. What should the nurse do next?

Set up supplemental oxygen delivery.

Increase the fraction of inspired oxygen.

Gather supplies for extubation.

Place a nasogastric tube.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Setting up supplemental oxygen delivery is not the immediate action the nurse should take. The patient’s FiO2 is currently at 35%, which is within the normal range.

Choice B rationale

Increasing the fraction of inspired oxygen is not necessary at this time. The patient’s current FiO2 is within the normal range.

Choice C rationale

The nurse should gather supplies for extubation. As the patient is due to start ventilator weaning, preparing for extubation is the next logical step. This involves having all necessary equipment and personnel ready for the procedure.

Choice D rationale

Placing a nasogastric tube is not the immediate action the nurse should take. While a nasogastric tube can be used to provide nutrition and medication, it is not directly related to the process of ventilator weaning.

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Correct Answer is C

Explanation

Choice A rationale

Increased BUN and serum creatinine are not typically symptoms of mononucleosis. These laboratory findings are more commonly associated with kidney dysfunction.

Choice B rationale

Ear pain and fever can be symptoms of many illnesses, including mononucleosis. However, they are not the most specific symptoms of this condition.

Choice C rationale

A positive Epstein-Barr virus test and malaise are common symptoms of mononucleosis. The Epstein-Barr virus is the most common cause of mononucleosis.

Choice D rationale

Elevated WBC and sedimentation rate can be seen in many inflammatory or infectious conditions, including mononucleosis. However, they are not the most specific symptoms of this condition.

A. Reassure the client that the nurse will return after all vital signs are taken. B. Pull up a chair and sit beside the client’s bed. C. Allow the client to hold the nurse’s hand until the vital signs can be completed. D. Tell the client that he must release the nurse’s hand.

Correct Answer is B

Explanation

Choice A rationale

Reassuring the client that the nurse will return after all vital signs are taken might not be the most appropriate action in this situation. The client is critically ill and might need immediate emotional support.

Choice B rationale

Pulling up a chair and sitting beside the client’s bed is the most appropriate action. This action shows empathy and provides emotional support, which is crucial in the care of critically ill patients.

Choice C rationale

Allowing the client to hold the nurse’s hand until the vital signs can be completed might provide some comfort to the client. However, it might not be feasible if the nurse needs to use both hands to complete the vital signs.

Choice D rationale

Telling the client that he must release the nurse’s hand might not be the most appropriate action. It might come across as dismissive and could potentially upset the client.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a child with mononucleosis.Which symptoms should the nurse expect the child to exhibit?

Correct Answer is C

Explanation

While taking vital signs, a critically ill male client grabs the nurse’s hand and asks the nurse not to leave.What is the most appropriate action for the nurse to take?

Correct Answer is B

Explanation

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound.Which action should the nurse take next?

A patient undergoing radiation treatment for laryngeal cancer has developed xerostomia and mucositis, leading to an imbalance in nutritional intake.What is the most likely reason for this issue?

After administering the prescribed albuterol nebulizer treatment, what should the nurse assess?

Exhibits Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.

The healthcare provider prescribes the antibiotic cefdinir 300 mg PO every 12 hours for a client with a postoperative wound infection.What foods should the nurse encourage this client to eat?