A nurse is checking a client's ventilator settings. The nurse should understand that positive end- expiratory pressure has which of the following purposes?

To deliver a set tidal volume

To provide positive airway pressure during inspiration

To control the rate of ventilations

To prevent alveolar collapse

Answer and Explanation

The Correct Answer is D

Positive end-expiratory pressure (PEEP) is a mode of mechanical ventilation that maintains a positive pressure in the airways at the end of expiration, preventing alveolar collapse and improving oxygenation. PEEP does not affect tidal volume, inspiratory pressure, or ventilation rate, which are determined by other ventilator settings.

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Correct Answer is C

Explanation

Altered level of consciousness (LOC) is the earliest and most sensitive indicator of increased ICP, which can result from brain injury, tumor, hemorrhage, infection, or edema.

The nurse should monitor the client's LOC using the Glasgow Coma Scale (GCS) and report any changes or deterioration to the provider. Pupillary dilation, decorticate posturing, and Cheyne-Stokes respirations are later signs of increased ICP that indicate brainstem compression and herniation, which are life-threatening emergencies.

A. Insert a saline lock into a site 10 cm (4 in) distal to the graft. B. Instruct the client to avoid lifting the right arm for 72 hr. C. Palpate the site for a thrill. D. Check blood pressure in the right arm.

Correct Answer is C

Explanation

Palpating the site for a thrill is an important action to assess the patency and function of an arteriovenous graft, which is a synthetic tube that connects an artery and a vein for hemodialysis access. A thrill is a vibration felt over the graft that indicates blood flow. The other options are incorrect because they could compromise or damage the graft.

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A nurse is checking a client's ventilator settings. The nurse should understand that positive end- expiratory pressure has which of the following purposes?

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Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has increased intracranial pressure (ICP). The nurse should recognize that which of the following is the first sign of deteriorating neurological status?

Correct Answer is C

Explanation

A nurse is planning care for a client who has a newly implanted arteriovenous graft in the right arm. Which of the following actions should the nurse include in the plan of care?

Correct Answer is C

Explanation

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