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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"A"},"B":{"answers":"C"},"C":{"answers":"B"},"D":{"answers":"B"}}
Explanation
Client Statement: A. The client seems unemotional when talking about needing to rebuild her house.
Suppression fits here because the client appears detached or unemotional when discussing the significant emotional task of rebuilding her house after it collapsed. This suggests a deliberate effort to suppress or minimize the emotional impact of the situation.
Client Statement: C. The client discusses moving to Hawaii instead of returning to rebuild her house.
The client's discussion of moving to Hawaii instead of facing the reality of rebuilding her house reflects a form of fantasy. It suggests a retreat into an idealized scenario (moving to a distant, idyllic location) to avoid dealing directly with the trauma and stress associated with rebuilding her home.
Client Statement: B. The client says that she sometimes forgets why she is in the hospital.
Isolation can be inferred here because the client's statement about forgetting why she is in the hospital may indicate a psychological distancing or detachment from the traumatic events that led her there. It suggests a coping mechanism where she separates her emotional distress (related to the house collapse) from the practical reality of being hospitalized and receiving treatment.
Client Statement: D. The client is frightened that the hospital will burn down.
This statement fits into the defense mechanisms of fantasy. The client encounters thoughts of the hospital burning and her house burns down.
Correct Answer is ["A","B","C"]
Explanation
Rationale
A. This involves visually inspecting the chest to ensure both sides rise and fall equally during ventilation. Symmetrical chest movement suggests that both lungs are being adequately ventilated.
B. Auscultation involves listening with a stethoscope over the chest to confirm the presence of breath sounds in both lung fields. Bilateral breath sounds indicate that the ETT is correctly positioned in the trachea, allowing air to reach both lungs.
C. A chest x-ray provides a definitive confirmation of the ETT placement in relation to the trachea and lungs. It allows visualization of the tube's position relative to anatomical landmarks, such as the carina, which helps ensure proper placement.
This involves checking the markings on the ETT tube to ensure it is inserted to the correct depth. Typically, the ETT should be positioned with its tip approximately 2 to 4 cm above the carina, which corresponds to the 22-26 cm mark at the teeth line in adults. However, it does not confirm correct placement.
E. Capillary refill is a measure of peripheral perfusion and is unrelated to ETT placement. It assesses circulatory status by pressing on a nail bed and observing the time it takes for color to return. It does not provide information about ETT placement.
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