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Exhibits

The nurse notifies the healthcare provider of the client's status. The healthcare provider comes to the bedside to evaluate the client.

Which should the nurse do? Select all that apply.

Increase the fraction of inspired oxygen

Suggest a different ventilator mode to the provider

Offer the client ice chips

Set the ventilator to give mandatory breaths

Set up supplemental oxygen delivery

Gather supplies for extubation

Place a nasogastric tube

Answer and Explanation

Correct Answer : B,E,F

A.   Since the client is already on a fraction of inspired oxygen (FIO2) of 35% and has successfully weaned off the ventilator, increasing the FIO2 may not be necessary unless the client's oxygenation status deteriorates post-extubation.
B.   As the client has successfully weaned off pressure support and is now at 0 cm H2O, the healthcare provider may consider transitioning to a different ventilator mode such as T-piece or CPAP (Continuous Positive Airway Pressure) to further assess the client's ability to breathe spontaneously without ventilator support.
C.   Ice chips are typically offered to conscious patients to alleviate thirst or dry mouth. The client was previously intubated and may not be fully conscious or able to swallow safely immediately post- extubation.
D.   Since the client has been weaned off pressure support successfully, there is no indication to set the ventilator to provide mandatory breaths. The focus is on assessing the client's ability to breathe spontaneously.
E.   Even though the client has been weaned off the ventilator, it's important to ensure adequate oxygenation. Setting up supplemental oxygen delivery, such as via nasal cannula or face mask, can support the client's oxygen needs during the transition phase post-extubation.
F.   Since the client has been successfully weaned to 0 cm H2O pressure support and the healthcare provider is evaluating the client, gathering supplies for potential extubation is appropriate. This includes ensuring all necessary equipment and supplies for a safe extubation procedure are readily available at the bedside.
G.   Unless specifically indicated for other medical reasons not mentioned, there is no immediate need to place a nasogastric tube based on the information provided about the client's current condition post- weaning.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Rationale

A. During a thoracentesis, a needle is inserted through the chest wall into the pleural space to remove fluid or air. It's common for clients to feel a stinging sensation or discomfort during needle insertion. The nurse should confirm this understanding with the client and reassure them that local anesthesia will be used to minimize discomfort.

B. The positioning described (sitting forward with arms propped on a table) helps to expand the intercostal spaces and facilitates easier access to the pleural space during the procedure. The nurse should reinforce this position as appropriate for the thoracentesis procedure.

C. This statement is incorrect and would indicate a need for additional education. A persistent cough is not an expected outcome after a thoracentesis. While some clients may experience a mild cough during or immediately after the procedure due to irritation from the needle or local anesthesia, it should not persist afterwards.

D. This statement is generally correct. After a thoracentesis, it is recommended to limit strenuous activity and avoid heavy lifting for a day or two to minimize the risk of complications such as discomfort or injury at the needle insertion site. The nurse should support this instruction as part of the client's post-procedure care.

A. Reposition the stethoscope over the brachial artery. B. Note the presence of an auscultatory gap. C. Continue with the blood pressure assessment. D. Reinflate the cuff to a higher number.

Correct Answer is B

Explanation

Rationale

A. Repositioning the stethoscope or reinflating the cuff may be necessary if the sounds are unclear or if there is difficulty in hearing the Korotkoff sounds, but these actions come after noting any auscultatory gap.

B. It's characterized by a period of silence between the appearance and disappearance of sounds. Noting its presence is important for accurately recording the blood pressure readings, as failure to recognize an auscultatory gap could lead to underestimating the systolic pressure.

C. After repositioning the stethoscope or noting the presence of an auscultatory gap, the nurse should proceed with the blood pressure assessment.

D. If the cuff was not inflated adequately during the initial inflation, the nurse may not have occluded the artery completely, leading to inaccurate readings. However, in this scenario where Korotkoff sounds

are heard, it indicates that the cuff pressure was sufficient to occlude and then release the artery's blood flow.

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Exhibits The nurse notifies the healthcare provider of the client's status. The healthcare provider comes to the bedside to evaluate the client. Which should the nurse do? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing a client for an outpatient thoracentesis. Which statement made by the client should the nurse recognize as needing additional education?

Correct Answer is C

Explanation

After inflating a blood pressure cuff and releasing the valve, the nurse hears silence followed by a Korotkoff sound. Which action should the nurse take next?

Correct Answer is B

Explanation

The parent of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The parent reports no evidence of watery stools. Which nursing intervention should the nurse implement?

Exhibits Which client statement(s) require(s) follow up teaching by the nurse? Select all that apply.

Which client is best to assign to the practical nurse (PN) who is assisting the registered nurse (RN) with the care of a group of clients?

A client with a history of inflammatory bowel disease develops severe ulcerative colitis and is admitted to the intensive care unit after surgery for a fistula repair. Which intervention is most important for the nurse to include in the plan of care?

The nurse is performing tracheostomy care for a client when a code blue is called for another client on the unit who experiences a cardiopulmonary arrest. Which action should the nurse take?

Exhibits

The nurse notifies the healthcare provider of the client's status. The healthcare provider comes to the bedside to evaluate the client.

Which should the nurse do? Select all that apply.