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

While auscultating breath sounds is an important part of assessing a client’s respiratory status, it is not the first action the nurse should take when a client with ascites is dyspneic. The nurse should first address the client’s positioning to help alleviate the dyspnea.

Choice B rationale

While measuring vital signs is an important part of assessing a client’s overall status, it is not the first action the nurse should take when a client with ascites is dyspneic. The nurse should first address the client’s positioning to help alleviate the dyspnea.

Choice C rationale

Assisting the client to a high Fowler’s position can help alleviate dyspnea by allowing for greater lung expansion. This should be the nurse’s first action when a client with ascites is dyspneic.

Choice D rationale

While deep breathing exercises can help improve lung function and may be beneficial for a client with ascites, they are not the first action the nurse should take when the client is dyspneic. The nurse should first address the client’s positioning to help alleviate the dyspnea.

A. Boggy fundus 1 cm above the umbilicus B. Fundus rotated to the right C. Voided 200 mL of clear yellow urine D. Blood pressure 90/62 mm Hg

Correct Answer is ["A","B"]

Explanation

Choice A rationale

A boggy fundus refers to an enlarged, soft, and tender uterus identified during physical examination. It is most commonly caused by uterine atony or adenomyosis. A boggy fundus 1 cm above the umbilicus requires immediate follow-up as it indicates that the uterus is not contracting properly after childbirth, which can lead to postpartum hemorrhage.

Choice B rationale

A fundus rotated to the right could indicate a distended bladder. This requires immediate follow-up as it can lead to urinary retention and other complications.

Choice C rationale

Voiding 200 mL of clear yellow urine is a normal finding and does not require immediate follow-up.

Choice D rationale

A blood pressure of 90/62 mm Hg is considered normal according to the American Heart Association. Therefore, it does not require immediate follow-up.

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Naxlex Comprehensive Predictor Exams

The nurse observes that a client with ascites is dyspneic.Which action should the nurse implement first?

Correct Answer is C

Explanation

The nurse is reviewing the nurse’s notes and flow chart to identify trends.Which notations require immediate follow-up?

Correct Answer is ["A","B"]

Explanation

A client has developed atrial fibrillation with a ventricular rate of 150 beats/minute observed via telemetry.The client’s blood pressure is 80/40 mm Hg. Which finding is most important for the nurse to report to the healthcare provider?

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What advice should a nurse give to a patient who is about to undergo a cystoscopy?

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Given the patient’s history and physical assessment findings, what is the most probable condition the patient has, and what could it be related to?

The parent of a 7-month-old infant visits the clinic due to the infant’s diaper area being red and raw, but without any blisters or bleeding.The parent reports no signs of watery stools.What nursing intervention should the nurse implement?