A nurse is caring for a client who is receiving mechanical ventilation following a stroke.
Which of the following actions should the nurse take?
Cluster nursing care activities.
Hyperoxygenate the client before suctioning.
Keep the room well lit to orient the client.
Maintain the client's PaCO2 at 50 mm Hg.
The Correct Answer is A
Choice A rationale:
Clustering nursing care activities minimizes disruptions to the client, reduces fatigue, and allows for periods of rest in between interventions.
Choice B rationale:
Hyperoxygenating the client before suctioning helps maintain adequate oxygenation and prevents hypoxia during the suctioning procedure.
Choice C rationale:
Keeping the room well lit is not necessary for a client on mechanical ventilation and can actually disturb their rest.
Choice D rationale:
Maintaining a specific PaCO2 level might be important for some clients, but this is not a general action applicable to all mechanically ventilated clients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Inflammatory bowel disease, including Crohn's disease, can lead to decreased albumin levels due to malabsorption and inflammation.
Choice B rationale:
Increased erythrocyte sedimentation rate (ESR) is more likely in inflammatory conditions.
Choice C rationale:
Decreased hematocrit is more common due to potential blood loss.
Choice D rationale:
Decreased protein levels are expected due to inflammation and malabsorption.
Correct Answer is D
Explanation
Choice A rationale:
Hot flashes are not typically associated with postpartum depression; they are more related to hormonal changes.
Choice B rationale:
Intermittent abdominal pain is common after childbirth due to uterine contractions and involution.
Choice C rationale:
Blurred vision is not a typical symptom of postpartum depression.
Choice D rationale:
Feelings of intense guilt are indicative of postpartum depression and require further investigation.
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