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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 A

Explanation

Choice A rationale

Watery diarrhea is a significant side effect of linezolid and could indicate a serious condition called antibiotic-associated colitis, which is caused by an overgrowth of the bacterium Clostridium difficile. This condition requires immediate medical attention.

Choice B rationale

Increased fatigue is a common side effect of many medications, including linezolid. While it should be reported to the healthcare provider, it is not as urgent as watery diarrhea.

Choice C rationale

Nausea and headache are common side effects of linezolid. While they should be reported to the healthcare provider, they are not as urgent as watery diarrhea.

Choice D rationale

Yellow-tinged sputum could indicate an infection or other lung condition. However, in the context of a patient receiving linezolid for nosocomial pneumonia, it is not as urgent as watery diarrhea.

A. Thick, dry, and dark area on bilateral heels. B. Broken skin without evidence of undermining. C. Defined area of persistent redness over bone. D. Superficial sacral pressure injury with defined margins.

Correct Answer is C

Explanation

Choice A rationale

A thick, dry, and dark area on the heels could indicate a more advanced stage of a pressure injury, not the earliest indication.

Choice B rationale

Broken skin without evidence of undermining could also indicate a more advanced stage of a pressure injury.

Choice C rationale

A defined area of persistent redness over a bony prominence is often the earliest sign of a developing pressure injury. This is because these areas are more susceptible to pressure and have less padding to protect them.

Choice D rationale

A superficial sacral pressure injury with defined margins is a more advanced stage of a pressure injury.

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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

A patient is receiving linezolid IV for nosocomial pneumonia.Which assessment finding is most important for the nurse to report to the healthcare provider?

Correct Answer is A

Explanation

A client admitted with pneumonia and on bedrest has not had the strength to perform self-care.Which assessment finding provides the nurse with the earliest indication that the client is developing a pressure injury?

Correct Answer is C

Explanation

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 admitting a client from the postanesthesia unit to the postoperative surgical care unit.Which prescription should the nurse implement first?

What breakfast option should a nurse suggest for a 16-year-old patient suffering from diarrhea?

A client newly diagnosed with type 1 diabetes mellitus (DM) asks the nurse to leave the room when the nurse tries to teach self-administration of insulin injections.What should the nurse do next?

When preparing a client for an intravenous pyelogram (IVP), it is essential for the nurse to take which action?

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