A client is admitted to the intensive care unit (ICU) with sepsis and acute respiratory distress syndrome (ARDS). The client is orally intubated and mechanically ventilated. Which intervention is most important for the nurse to include in the client's plan of care (POC)?

Teach communication board use.

Use antiseptic solution with oral care.

Recommend hours for visitation.

Promote uninterrupted periods of sleep.

Answer and Explanation

The Correct Answer is B

A. Teach communication board use. While nonverbal communication tools are helpful for intubated clients, they do not directly prevent complications associated with mechanical ventilation and ARDS. The priority in this critically ill client is to prevent ventilator-associated pneumonia (VAP) and sepsis-related complications.
B. Use antiseptic solution with oral care. Clients on mechanical ventilation are at high risk for ventilator-associated pneumonia (VAP), which worsens outcomes in ARDS. Using an antiseptic solution (such as chlorhexidine) for oral care reduces bacterial colonization in the oropharynx, decreasing the risk of VAP. This intervention is a key component of ventilator bundle protocols to improve survival rates in critically ill patients.
C. Recommend hours for visitation. While family support is important, setting visitation hours does not directly impact the client's recovery from ARDS and sepsis. Infection prevention and lung protection strategies take higher priority in the acute phase.
D. Promote uninterrupted periods of sleep. Rest is important for critically ill clients, but preventing life-threatening complications such as VAP, sepsis progression, and oxygenation failure takes precedence. Proper oral care with antiseptics directly reduces infection risk and improves patient outcomes.

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 B

Explanation

A. Administer famotidine 20 mg IV. Famotidine is a histamine-2 receptor antagonist used for stress ulcer prophylaxis in critically ill patients. While this medication may be beneficial, it is not the priority intervention based on the insulin protocol and the client's blood glucose level.
B. Titrate insulin infusion by 1 unit/hour. The client’s blood glucose is 160 mg/dL, which falls within the 150–199 mg/dL range according to the insulin protocol. The protocol directs the nurse to increase the insulin drip rate by 1 unit/hour to maintain blood glucose levels below 150 mg/dL. This is the most immediate and appropriate action.
C. Increase dopamine 2 mcg/kg. The client’s MAP is 66 mmHg, which meets the protocol goal of keeping MAP >65 mmHg. There is no indication for increasing dopamine at this time, as the blood pressure is already within the target range.
D. Raise oxygen by 10 percent. The client is on 50% FiO₂ via a face mask with an oxygen saturation of 92%, which is adequate oxygenation for a critically ill patient. Increasing FiO₂ unnecessarily may contribute to oxygen toxicity and is not required based on current oxygenation status.

A. Expel the excess air and heparin from the syringe. B. Place sample in arterial blood gas syringe. C. Obtain a minimum of 1 mL of blood. D. Aspirate the blood sample slowly.

Correct Answer is C

Explanation

A. Expel the excess air and heparin from the syringe. While removing excess air prevents gas exchange alterations, this is not the priority when obtaining an SVO₂ sample. Excess heparin could dilute the sample, but proper blood volume collection is the first concern.
B. Place sample in arterial blood gas syringe. SVO₂ measures venous oxygen saturation, which is different from arterial blood gases (ABGs). Using an ABG syringe is incorrect because it is heparinized for arterial sampling, and arterial blood does not reflect mixed venous oxygenation.
C. Obtain a minimum of 1 mL of blood. SVO₂ is measured from the distal lumen of a pulmonary artery (PA) catheter to assess oxygen delivery and consumption. At least 1 mL of blood is required for an accurate reading, ensuring sufficient sample volume for laboratory analysis.
D. Aspirate the blood sample slowly. While slow aspiration can help prevent hemolysis, it is not the primary concern when collecting an SVO₂ sample. The priority is obtaining a sufficient volume (≥1 mL) for an accurate measurement.

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

A client is admitted to the intensive care unit (ICU) with sepsis and acute respiratory distress syndrome (ARDS). The client is orally intubated and mechanically ventilated. Which intervention is most important for the nurse to include in the client's plan of care (POC)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

The nurse is collecting a blood sample for a mixed venous oxygen saturation (SVO2) level from the distal lumen of a pulmonary artery (PA) catheter of a client in cardiogenic shock. Which action should the nurse implement?

Correct Answer is C

Explanation

The nurse identifies the collaborative problem of potential electrolyte imbalance in a client with acute pancreatitis. Which assessment finding should the nurse associate with an electrolyte imbalance related to acute pancreatitis?

A client, who is 4 hours postoperative laparotomy, has rapidly increasing abdominal distention with elevated pulse and respiratory rates. The client's skin is cool and pale, and there is no change in the blood pressure. Which intervention should the nurse implement immediately?

The nurse is evaluating a client's central venous pressure (CVP) also called right atrial pressure (RAP) readings that are trending upwards. Which nursing problem is supported by the pathophysiologic mechanism most likely causing the increases?

A client has been treated for uncontrolled atrial fibrillation with cardioversion. Following the cardioversion, which assessment finding indicates to the nurse that the desired outcome was achieved?

A client with a gunshot wound is brought to the emergency department (ED) with a bullet entry at the spinal level of C8 and T1.The client is able to move the upper arms. To further assess the client's spinal nerve function, which action should the nurse implement?