A nurse is assisting with weaning a client from the ventilator. Which of the following parts of the ABCDEF assessment tool does the weaning process represent?

Choice of Analgesia and Sedation

Assess, Prevent, and Manage Pain

Delirium: Assess, Prevent, and Manage

Breathing: Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT)

Answer and Explanation

The Correct Answer is D

A. The "Choice of Analgesia and Sedation" component of the ABCDEF assessment tool focuses on selecting appropriate pain relief and sedation strategies for the patient but does not directly relate to the weaning process.
B. "Assess, Prevent, and Manage Pain" involves ensuring the patient is comfortable and free from pain, which is important but not specifically related to weaning from the ventilator.
C. "Delirium: Assess, Prevent, and Manage" addresses the cognitive status of the patient, particularly the prevention and management of delirium, which is a critical aspect of care but not directly related to ventilator weaning.
D. "Breathing: Spontaneous Awakening Trials (SAT) and Spontaneous Breathing Trials (SBT)" directly involves the weaning process, as it includes assessing the patient's ability to breathe independently by reducing or removing sedation (SAT) and evaluating their capacity for spontaneous breathing (SBT).

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Correct Answer is C

Explanation

A. The intracellular space contains most of the body's water: While it is true that the intracellular space holds the majority of the body's water, this statement does not specifically relate to the concept of fluid volume deficit or how the body responds to it.

B. A fluid volume deficit inhibits baroreceptors: In fact, fluid volume deficit activates baroreceptors due to reduced blood pressure, leading to compensatory mechanisms like increased heart rate and vasoconstriction to maintain blood pressure.

C. When the body loses water, the intravascular space experiences the water loss: This statement accurately describes the process during fluid volume deficit. The intravascular space loses water, leading to decreased blood volume, which can result in symptoms like hypotension and reduced tissue perfusion.

D. A negative fluid balance occurs when the body takes in more water than the body needs: This statement is incorrect; a negative fluid balance occurs when the body loses more water than it takes in, leading to dehydration or fluid volume deficit.

A. Dyspnea B. Chronic cough C. Wheezing D. Sputum production E. Chest tightness

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

Explanation

A. Dyspnea: Shortness of breath or difficulty breathing is a hallmark symptom of COPD, commonly reported by patients.

B. Chronic cough: A persistent cough, often productive, is a common manifestation of COPD, reflecting the chronic inflammation and irritation of the airways.

C. Wheezing: Wheezing, a high-pitched whistling sound during breathing, is often present in COPD due to airway narrowing and obstruction.

D. Sputum production: Increased production of sputum (mucus) is typical in COPD, as the chronic inflammation leads to mucus hypersecretion.

E. Chest tightness: While chest tightness can occur in COPD, it is less common compared to the more prominent symptoms of dyspnea, chronic cough, wheezing, and sputum production.

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A nurse is assisting with weaning a client from the ventilator. Which of the following parts of the ABCDEF assessment tool does the weaning process represent?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is reinforcing teaching to a graduating nurse about fluid volume deficit. Which of the following concepts about water balance should the nurse explain to the graduating nurse?

Correct Answer is C

Explanation

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

Explanation

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