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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.
Potential Actions

Set up supplemental oxygen delivery

Increase the fraction of inspired oxygen

Gather supplies for extubation

Place a nasogastric tube

Offer the client ice chips

Suggest a different ventilator mode to the provider

Set the ventilator to give mandatory breaths

Answer and Explanation

Correct Answer : A,C,E

A. Set up supplemental oxygen delivery - This could be necessary as the client is being weaned off the ventilator and may require additional oxygen support.
C. Gather supplies for extubation - As the client is being weaned off the ventilator and the pressure support has been decreased to 0 cm H2O, extubation may be imminent.
E. Offer the client ice chips - Once extubated, the client may have a dry mouth and throat from the intubation tube. Ice chips can help soothe the throat and keep the mouth moist.

B. Increase the fraction of inspired oxygen - This action is not indicated based on the information provided. The client’s oxygen saturation is within normal range and there’s no indication that the client is experiencing difficulty breathing or hypoxia.
D. Place a nasogastric tube - There’s no indication in the scenario that the client has a need for a nasogastric tube. This procedure is typically done for clients who have difficulty swallowing or need help with feeding, neither of which is mentioned in the scenario.
F. Suggest a different ventilator mode to the provider - The client is already being successfully weaned off the ventilator, as indicated by the decreasing pressure support. There’s no indication in the scenario that a different ventilator mode is needed.
G. Set the ventilator to give mandatory breaths - This action would be counterproductive to the weaning process. The client is already on a ventilator mode with no mandatory breaths and is being successfully weaned off the ventilator.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Choice A rationale

There is no indication that Patient D, who is scheduled for an appendectomy and has a white blood cell (WBC) count of 14,000 mm² (14 x 10°/L), needs to be transferred to an isolation room 24 hours prior to surgery.

Choice B rationale

Patient A, diagnosed with emphysema and has an oxygen saturation of 94% on room air, does not necessarily need an increase in oxygen. An oxygen saturation of 94% is within normal limits.

Choice C rationale

Patient B, who is postoperative with a hemoglobin level of 8.2 mg/dL (82 g/L), may require a blood transfusion. A hemoglobin level of 8.2 mg/dL is low, and having packed cells available is a prudent measure.

Choice D rationale

Patient C, newly admitted with a potassium level of 3.8 mEq/L (3.8 mmol/L), has a normal potassium level. Including a banana in the breakfast tray is not a priority.

A. Assist the spouse and carefully give the patient small sips of water. B. Obtain thickening powder before providing any more fluids. C. Ask the spouse to stop and assess the patient’s swallowing reflex. D. Give the spouse a straw to help facilitate the patient’s drinking.

Correct Answer is C

Explanation

Choice A rationale

Assisting the spouse and carefully giving the patient small sips of water may seem like a compassionate action. However, it could potentially lead to aspiration if the patient’s swallowing reflex is compromised, which is common in stroke patients.

Choice B rationale

While obtaining thickening powder before providing any more fluids can help prevent aspiration in patients with dysphagia, it is not the immediate action the nurse should take. The nurse first needs to assess the patient’s swallowing reflex before deciding on the appropriate intervention.

Choice C rationale

The nurse should ask the spouse to stop and assess the patient’s swallowing reflex. This is the most immediate and appropriate action. Stroke patients often have impaired swallowing reflexes, which can lead to aspiration if not properly managed. By assessing the swallowing reflex, the nurse can determine the best course of action to ensure the patient’s safety.

Choice D rationale

Giving the spouse a straw to help facilitate the patient’s drinking is not the best course of action. Straws can increase the risk of aspiration in patients with impaired swallowing reflexes. The nurse should first assess the patient’s swallowing reflex before deciding on the appropriate intervention.

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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. Potential Actions

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

Correct Answer is C

Explanation

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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.
Potential Actions