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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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

Choice A rationale

Changing the surgical dressing promptly when it becomes soiled is crucial to minimize the risk of a MRSA recurrence in the postoperative wound. A soiled dressing can become a medium for bacterial growth, including MRSA, and can potentially contaminate the wound.

Choice B rationale

Monitoring for any increase in the white blood cell count is important in detecting an infection, including a MRSA infection. However, it is not the most crucial intervention to minimize the risk of a MRSA recurrence in the postoperative wound.

Choice C rationale

Educating the family on the importance of adhering to contact precautions is important in preventing the spread of MRSA. However, it is not the most crucial intervention to minimize the risk of a MRSA recurrence in the postoperative wound.

Choice D rationale

Wearing a face mask while performing wound care can help prevent the spread of MRSA. However, it is not the most crucial intervention to minimize the risk of a MRSA recurrence in the postoperative wound.

A. Refer the client to the social worker for support therapy. B. Leave the client’s room and return later in the day. C. Explain that insulin is a life-saving drug for the client. D. Encourage the client to implement relaxation techniques.

Correct Answer is B

Explanation

Choice A rationale

While social workers can provide support therapy, they are not typically involved in teaching medical procedures like insulin injection15.

Choice B rationale

Leaving the room and returning later can give the client time to process the information and prepare for learning. It’s important to respect the client’s feelings and readiness to learn15.

Choice C rationale

While it’s true that insulin is a life-saving drug for people with type 1 diabetes, simply explaining this may not address the client’s fears or concerns about self-injection15.

Choice D rationale

Encouraging relaxation techniques can be helpful, but it doesn’t directly address the issue of teaching insulin injection15.

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Naxlex Comprehensive Predictor Exams

A nurse is caring for a patient who has undergone a small bowel resection and has a history of methicillin-resistant Staphylococcus aureus (MRSA). Which nursing intervention is most crucial to minimize the risk of a MRSA recurrence in the postoperative wound?

Correct Answer is A

Explanation

A client newly diagnosed with type 1 diabetes mellitus (DM) asks the nurse to leave the room when the nurse tries to teach self-administration of insulin injections.What should the nurse do next?

Correct Answer is B

Explanation

A patient weighing 132 lb is prescribed lorazepam 44 mcg/kg IV to be administered 20 minutes before a scheduled procedure. The medication is available in a 2 mg/mL vial. How many mL should the nurse administer? Round off to 2 d.p. (This is a medical math nd does not require options.)

A client is two hours postoperative from a cardiac catheterization via the right femoral artery.Which assessment finding indicates arterial obstruction?

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

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.

An older adult client informs the nurse of having a high-density lipoprotein (HDL) level of 85 mg/dL (2.2 mmol/L). What action should the nurse take?

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

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

A child weighing 55 lb has been prescribed cefotaxime at a dosage of 150 mg/kg/day, to be administered in divided doses every 6 hours. How many mg should the nurse administer each day? (Provide a numerical value only.)