A client who has been on a mechanical ventilator for three days develops a fever of 101 degrees Fahrenheit green sputum, and right lower lobe crackles. The nurse contacts the physician regarding possible development of which complication?

Ventilator -associated pneumonia

Pulmonary embolism

Stress ulcer

Pneumothorax

Answer and Explanation

The Correct Answer is A

A) Ventilator-associated pneumonia (VAP):
Ventilator-associated pneumonia (VAP) is a type of pneumonia that develops in patients who have been on mechanical ventilation for more than 48 hours. It is a common and serious complication in critically ill patients on ventilators. Symptoms such as fever, green sputum, and right lower lobe crackles are indicative of a respiratory infection, which, in this case, is most likely VAP. VAP typically presents with signs of infection such as elevated temperature, purulent sputum, and new infiltrates on a chest x-ray, in addition to lung crackles.

B) Pulmonary embolism (PE):
Although pulmonary embolism (PE) can cause symptoms like tachypnea, chest pain, and dyspnea, it does not typically cause a fever, green sputum, or localized crackles in the lungs. PE is usually characterized by sudden onset of respiratory distress, often accompanied by hemoptysis or chest pain, and would not typically present with the localized findings in the lower lobe (e.g., crackles).

C) Stress ulcer:
Stress ulcers can occur in critically ill patients, especially those on mechanical ventilation, due to the stress response and reduced blood flow to the stomach. However, stress ulcers typically cause gastrointestinal symptoms, such as melena (black, tarry stools) or hematemesis (vomiting blood).

D) Pneumothorax:
A pneumothorax occurs when air accumulates in the pleural space, causing a collapse of the lung. It can lead to symptoms such as sudden chest pain, dyspnea, and diminished breath sounds on one side of the chest. However, it would not typically cause fever, green sputum, or localized crackles.

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Free Nursing Study Resources

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

Explanation

A) O- (O negative):
A person with blood type A- can safely receive blood from a universal donor blood type, which is O-. This is because O- has no A, B, or Rh antigens on the surface of its red blood cells, making it compatible with any ABO blood group. The Rh negative status is also compatible, as the recipient is also Rh-negative.

B) AB- (AB negative):
A person with blood type A- cannot receive blood from someone with AB-. This is because the AB- blood type contains both A and B antigens on the surface of red blood cells, which could cause an immune reaction in a person with A- blood, whose immune system will react against the B antigen. Therefore, AB- is not compatible with A- blood.

C) A+ (A positive):
A person with A- blood cannot receive blood from an A+ donor, because the A+ blood contains the Rh positive antigen. If a person with A- blood receives Rh-positive blood, they will form antibodies against the Rh factor, leading to a hemolytic transfusion reaction. Therefore, A+ is not compatible with A- blood.

D) A- (A negative):
A person with A- blood can receive blood from another A- donor, because both share the A antigen and are Rh-negative. This is a perfect match and poses no risk of a transfusion reaction.

E) O+ (O positive):
A person with A- blood cannot receive blood from an O+ donor, because the O+ blood contains the Rh-positive antigen. This could cause an immune reaction in a person with A- blood, leading to the production of anti-Rh antibodies. Therefore, O+ is not compatible with A- blood.

A. Ensure bed alarm is on when leaving patient's room B. Vary schedule to prevent memorization and boredom C. Clarify misinformation and reorient when confused D. Deep breathing and incentive spirometer education

Correct Answer is A

Explanation

A) Ensure bed alarm is on when leaving patient's room:
The cerebellum plays a critical role in coordinating movement, balance, and motor control. An injury to this area can lead to impaired coordination and dysfunction in balance, making it difficult for the patient to perform the Romberg test (which evaluates balance and proprioception). Given that the patient cannot complete the Romberg test, this suggests the risk of falling or injuring themselves due to impaired balance and coordination. The priority nursing intervention is to ensure safety by using a bed alarm to alert staff if the patient attempts to get out of bed, thereby preventing falls.

B) Vary schedule to prevent memorization and boredom:
While changing the patient's routine may help with engagement, it is not the priority intervention for a patient with cerebellar injury. The primary concern in this situation is safety due to the patient's impaired balance. Addressing issues related to cognitive function or boredom may be important but comes after ensuring the patient’s physical safety.

C) Clarify misinformation and reorient when confused:
Reorientation may be necessary if the patient is confused or disoriented, but this is not the primary concern related to cerebellar injury. The patient’s balance and motor coordination are the most pressing issues. While mental clarity is important, preventing falls due to impaired motor control is the immediate priority.

D) Deep breathing and incentive spirometer education:
Deep breathing exercises and using an incentive spirometer are essential to prevent respiratory complications, particularly after surgery or immobility. However, in this case, the priority concern is the patient's safety related to impaired balance from the cerebellar injury. Respiratory interventions are important but should be addressed after ensuring that the patient is safe from falls and other immediate physical risks.

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A client who has been on a mechanical ventilator for three days develops a fever of 101 degrees Fahrenheit green sputum, and right lower lobe crackles. The nurse contacts the physician regarding possible development of which complication?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer a unit of packed red blood cells (PRBC's) to a patient whose blood type is A- (negative). The nurse knows that this patient can receive transfusions from which blood types? (SELECT ALL THAT APPLY).

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

Explanation

The nurse is caring for a patient diagnosed with an injury to the cerebellum who cannot complete the Romberg Test. Which nursing intervention is priority?

Correct Answer is A

Explanation

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