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:
Absent deep tendon reflexes can be a sign of magnesium toxicity, which is a potential adverse effect of magnesium sulfate infusion.
Choice B rationale:
A fetal heart rate of 120/min is within a normal range and is not concerning.
Choice C rationale:
Blood pressure of 150/92 mm Hg is elevated but is expected in a client with preeclampsia.
Choice D rationale:
Facial flushing can be a common side effect of magnesium sulfate and is not a priority finding to report.
Correct Answer is B
Explanation
Choice A rationale:
Using a disposable adhesive probe when measuring the client's SaO2 is not an intervention that can reduce the exposure of the client to latex, because adhesive probes may contain latex and cause skin reactions. A better option would be to use a non-adhesive probe or a probe cover that is latex-free.
Choice B rationale:
Rationale: Latex sensitivity or allergy can lead to adverse reactions when exposed to latex- containing products, such as blood pressure cuffs. Wrapping the blood pressure cuff in a stockinette helps minimize direct contact between the cuff and the client's skin.
Choice C rationale:
Silicone products are usually considered safe for individuals with latex sensitivity because silicone is a different material. Silicone products are generally safe for clients who are sensitive to latex, unless they have a separate allergy to silicone.
Choice D rationale:
Cleaning vial stoppers for 15 seconds before using them to withdraw-medications for the client is not an intervention that can reduce the exposure of the client to latex, because vial stoppers may be made of latex or rubber and cleaning them does not remove the allergen. A better option would be to use vials that have latex-free stoppers or to avoid puncturing the stoppers with needles.
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