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Exhibits

Based on the client's status at 1400, the nurse should plan to do which of the following? Select all that apply.

Increase the fractional concentration of Inspired oxygen

Change the ventilator settings to continuous positive airway pressure (CPAP)

Increase the respiratory rate

Continue weaning the ventilator as ordered

Decrease the tidal volume

Alert the provider of the blood gas values

Switch the ventilator to pressure control

Answer and Explanation

Correct Answer : A,F,G

A.   Increase the fractional concentration of Inspired oxygen: As the partial pressure of oxygen (PaO) has decreased to 64 mm Hg from 99 mm Hg, and the oxygen saturation may drop, it's necessary to increase the fraction of inspired oxygen (FiO2) to maintain adequate oxygenation.
B.   Change the ventilator settings to continuous positive airway pressure (CPAP): CPAP is not typically used in patients who are intubated. CPAP is a non-invasive ventilation mode used for patients with respiratory distress who are breathing spontaneously. In this case, the patient is intubated and requires mechanical ventilation, so CPAP is not appropriate.
C.   Increase the respiratory rate: While the respiratory rate has decreased from 15 to 13 breaths/minute, it's important to maintain a careful balance when adjusting ventilator settings. Increasing the respiratory rate may not be necessary at this point, especially if the patient is still oxygenating adequately. Moreover, the primary concern appears to be hypoxemia rather than hypoventilation.
D.   Continue weaning the ventilator as ordered: While weaning the patient off the ventilator is a goal, it may not be appropriate at this time, especially with the worsening blood gas values
indicating respiratory insufficiency. Continuing the weaning process could potentially exacerbate respiratory failure.

E. Decrease the tidal volume: Decreasing the tidal volume could worsen ventilation-perfusion matching and exacerbate hypoxemia. This approach might be considered in certain cases of acute respiratory distress syndrome (ARDS) or in patients with severe lung injury, but it's not typically indicated in this scenario without further assessment.

F. Alert the provider of the blood gas values: The nurse should inform the provider about the changes in blood gas values, especially the decrease in PaO2 and the increase in PaCO2, which indicate worsening respiratory status and potential respiratory acidosis.

G. Switch the ventilator to pressure control: Given the deterioration in respiratory status with an increase in PaCO2 and decrease in PaO2, switching to pressure control ventilation may provide better control over the patient's ventilation and oxygenation, especially in cases of acute
respiratory failure.

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Correct Answer is D

Explanation

A. "How do you cope with the voices?" is an important question to assess the client's coping mechanisms, but it does not provide direct information about the content or nature of the auditory hallucinations. While coping strategies are relevant, understanding the nature of the hallucinations is crucial for treatment planning.

B. "When do you hear voices?" is important to understand the timing and frequency of the hallucinations, but it does not provide information about the content or nature of the hallucinations themselves.

C. "Which medication works best?" is important to assess the client's previous treatment history and response to medication, but it does not directly address the current assessment of the auditory hallucinations.

D. "What are the voices saying?" is the most important question because it directly addresses the content and nature of the auditory hallucinations. Understanding the specific content, tone, and perceived significance of the voices can provide valuable information for diagnosis, treatment planning, and assessing the client's level of distress or impairment.

A. An adult client with no postoperative drainage in the Jackson-Pratt drain with the bulb compressed. B. An adult client with a rectal tube draining clear, pale red liquid drainage. C. An older client with a distended abdomen and no drainage from the nasogastric tube. D. An older client with dark red drainage on a postoperative dressing, but no drainage in the Hemovac.

Correct Answer is A

Explanation

A. An adult client with no postoperative drainage in the Jackson-Pratt drain with the bulb compressed. This client is stable with no drainage from the Jackson-Pratt drain, indicating that there is no immediate issue that needs to be addressed. The bulb is compressed, suggesting proper function. Therefore, this client can be safely assessed last.
B. An adult client with a rectal tube draining clear, pale red liquid drainage. The presence of pale red drainage can indicate a potential issue that needs monitoring, such as bleeding or other complications, thus requiring a more timely assessment.

C. An older client with a distended abdomen and no drainage from the nasogastric tube. A distended abdomen and lack of drainage could indicate a blockage or other serious issue that needs immediate attention.
D. An older client with dark red drainage on a postoperative dressing, but no drainage in the Hemovac. Dark red drainage can indicate active bleeding, which is a critical issue that needs to be addressed promptly to prevent complications.

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Exhibits Based on the client's status at 1400, the nurse should plan to do which of the following? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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Exhibits

Based on the client's status at 1400, the nurse should plan to do which of the following? Select all that apply.