A nurse is caring for a client in the emergency department (ED).

Exhibits
Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

AF is characterized by irregular, rapid heartbeat (100 to 175 beats per minute (bpm) and the absence of distinct P waves.

Management of unstable atrial fibrillation include immediate pharmacological or electrical cardioversion and anticoagulation.

Atrial fibrillation leads to ineffective pumping and stasis of blood in the heart which increases the risk of stroke.

On initiating anticoagulation, PTT/INR is important to ensure that the drug is administered at doses that achieve the optimal therapeutic effect.

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Correct Answer is B

Explanation

B. In a closed chest drainage system, slow and steady bubbling in the suction control chamber is typically an expected finding, as it indicates that the suction is active and functioning properly

A. Checking the tubing connections for leaks or the suction control outlet on the wall might be necessary if there were signs of a problem with the system's function.

C. Checking the suction control outlet on the wall is a reasonable action to ensure that the suction source is functioning appropriately and delivering the prescribed suction pressure to the chest drainage system. If there are any issues with the suction control outlet, they should be addressed to maintain proper suction.

D. Clamping the chest tube is not indicated based solely on the presence of slow, steady bubbling in the suction control chamber. Clamping the chest tube could obstruct drainage and lead to complications such as tension pneumothorax or retained hemothorax.

A. Position the head of the client's bed in the flat position. B. Provide humidity by maintaining moisture within the ventilator tubing. C. Turn the client every 4 hr. D. Brush the client's teeth with a suction toothbrush every 12 hr.

Correct Answer is D

Explanation

D. Oral hygiene is crucial in reducing the risk of VAP as it helps to reduce the bacterial load in the oral cavity, which can be aspirated into the lower respiratory tract. Using a suction toothbrush to mechanically remove dental plaque and bacteria from the teeth and oral mucosa can help to prevent VAP.

A. Elevating the head of the bed to between 30 and 45 degrees (semi-recumbent position) is recommended to prevent aspiration of oral or gastric contents, which can contribute to the development of VAP. This position helps to promote drainage of secretions and reduces the risk of reflux.

B. While maintaining appropriate humidity levels in the ventilator tubing helps to prevent drying of the respiratory mucosa and promote secretion clearance, it does not directly reduce the risk of VAP. Other interventions are more directly related to VAP prevention.

C. Regular turning and repositioning of the client help to prevent pooling of secretions, improve ventilation-perfusion matching, and reduce the risk of pressure ulcers. Turning the client every 2 hours is often recommended to optimize lung expansion and secretion clearance, thereby reducing the risk of VAP.

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Naxlex Comprehensive Predictor Exams

A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following actions should the nurse take to reduce the risk of ventilator- associated pneumonia?

Correct Answer is D

Explanation

A nurse is assessing a client who has atrial fibrillation. Which of the following pulse characteristics should the nurse expect?

Which of the following is NOT an appropriate indication for the use of dopamine in critical care?

Which of the following factors can directly affect cardiac output?

When admitting a patient with possible respiratory failure and a high PaCO2, which assessment information should be immediately reported to the health care provider?

Norepinephrine has been prescribed for a patient who was admitted with dehydration and hypotension. Which data indicate that the nurse should consult with the health care provider before starting the norepinephrine?

A client with acute respiratory distress syndrome (ARDS) shows no improvement despite increases in concentration in oxygen administered. What intervention should the nurse attempt which may improve ventilation-perfusion matching?

A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?