A nurse is caring for a client in acute respiratory failure who is receiving mechanical ventilation. Which of the following assessments is the best method to determine the effectiveness of the current treatments?

Arterial Blood Gas (ABG)

Blood pressure

Capillary refill

Heart rate

Answer and Explanation

The Correct Answer is A

Choice A reason:

Arterial Blood Gas (ABG) analysis is the best method to determine the effectiveness of treatments in a client receiving mechanical ventilation. ABGs provide direct information about the patient's oxygenation, ventilation, and acid-base status, which are critical in managing acute respiratory failure.

Choice B reason:

While blood pressure is important for overall patient monitoring, it does not provide specific information about the effectiveness of ventilation and respiratory status. It is more related to hemodynamic stability.

Choice C reason:

Capillary refill can provide some information about peripheral perfusion but is not specific enough to assess the effectiveness of mechanical ventilation or respiratory treatments.

Choice D reason:

Heart rate is a vital sign that can indicate the patient's overall condition but does not specifically assess the effectiveness of ventilation or respiratory treatments. It should be considered along with other more specific respiratory assessments.

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Correct Answer is B,A,C

Explanation

Choice A reason:

Completing a Glasgow Coma Scale assessment is crucial in evaluating the neurological status of a patient with a suspected traumatic cervical spine injury. However, it should be done after ensuring that there is no uncontrolled bleeding.

Choice B reason:

Applying pressure to any areas of uncontrolled bleeding is the highest priority. Controlling bleeding is essential to prevent hypovolemic shock and maintain hemodynamic stability, which takes precedence over other assessments and interventions.

Choice C reason:

Placing an indwelling Foley catheter to monitor urine output is important for ongoing assessment of renal function and fluid balance. However, it is not the immediate priority compared to controlling bleeding and assessing neurological status.

A. A 72-year-old client with a brain tumor, GCS of 5 and decerebrate posturing. B. A 24-year-old client after a motor vehicle accident with a Glasgow Coma Scale (GCS) of 3 and no activity on electroencephalogram. C. A 68-year-old male admitted with a massive stroke and GCS of 6. D. A 50-year-old female client after a motor vehicle accident and surgical evacuation of an epidural hematoma, Glasgow Coma Scale 12.

Correct Answer is B

Explanation

Choice A reason:

A 72-year-old client with a brain tumor, GCS of 5, and decerebrate posturing may not be an ideal candidate for organ donation due to age and underlying cancer, which can affect organ viability.

Choice B reason:

A 24-year-old client after a motor vehicle accident with a GCS of 3 and no activity on electroencephalogram is a prime candidate for organ donation. The lack of brain activity indicates brain death, and the patient's young age and otherwise healthy organs make them suitable for transplantation.

Choice C reason:

A 68-year-old male with a massive stroke and GCS of 6 has significant neurological impairment but is not necessarily brain dead. Further evaluation would be required, but this patient may not meet the criteria for brain death necessary for organ donation.

Choice D reason:

A 50-year-old female with a GCS of 12 after surgical evacuation of an epidural hematoma is not an ideal candidate for organ donation at this time as they have a higher level of consciousness and potential for recovery.

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A nurse is caring for a client in acute respiratory failure who is receiving mechanical ventilation. Which of the following assessments is the best method to determine the effectiveness of the current treatments?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a patient with suspected traumatic cervical spine injury who just arrived to the emergency department. The nurse knows the priority actions for caring for this patient include all of the following. Place the actions in order of priority.

Correct Answer is B,A,C

Explanation

A charge nurse is reviewing the status of patients in the critical care unit. Which patient should the charge nurse notify the organ procurement team to evaluate for possible organ donation?

Correct Answer is B

Explanation

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