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 B
Explanation
Choice A rationale:
A fasting blood glucose level of 96 mg/dL is within a normal range and is not typically associated with carbidopa/levodopa therapy.
Choice B rationale:
Hemoglobin levels of 10 g/dL may indicate anemia, which can exacerbate symptoms in clients with Parkinson's disease and affect the effectiveness of carbidopa/levodopa.
Choice C rationale:
A platelet count of 200,000/mm3 is within a normal range and is not typically associated with carbidopa/levodopa therapy.
Choice D rationale:
A blood urea nitrogen (BUN) level of 10 mg/dL is within a normal range and is not typically associated with carbidopa/levodopa therapy.
Correct Answer is B
Explanation
Choice A rationale:
Referring the client to crisis intervention services might be necessary, but before doing so, the nurse should gather information to understand the client's current situation and coping mechanisms.
Choice B rationale:
Assessing the client's previous coping methods helps the nurse understand the client's strengths and provides insights into potential strategies for managing the crisis effectively.
Choice C rationale:
Discussing the cause of the crisis might be helpful, but it's important to first assess the client's current coping abilities and resources.
Choice D rationale:
Assisting the client in developing strategies to overcome the crisis is important, but it should come after a thorough assessment of the client's current coping mechanisms and situation.
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