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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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Correct Answer is D

Explanation

Choice A rationale

Serum albumin levels can be relevant in assessing nutritional status and the body’s ability to heal wounds. However, they do not directly indicate the presence of infection or purulent drainage.

Choice B rationale

Hematocrit measures the percentage of red blood cells in the blood and is not directly related to the presence of purulent drainage at a burn wound site. Elevated hematocrit may indicate dehydration or hemoconcentration but does not specifically address the issue of wound infection.

Choice C rationale

Serum blood glucose (BG) level is not directly related to the presence of purulent drainage at a burn wound site. Elevated BG levels might be seen in clients with diabetes or as a stress response, but they are not the primary indicator of infection or wound complications.

Choice D rationale

Neutrophil count is a key laboratory value to note when a client with a full-thickness burn has purulent drainage at the wound. An elevated neutrophil count can indicate an infection, which could be the cause of the purulent drainage.

A. Check capillary refill on bilateral upper extremities. B. Administer ondansetron 4 mg IV. C. Inspect the bandage for drainage.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"}}

Explanation

Based on the provided information, here are the interventions the nurse should perform:

Check capillary refill on bilateral upper extremities.- Indicated: This is important to assess the client’s circulation, especially given the coolness of the left arm and the fracture in the left shoulder.
Administer ondansetron 4 mg IV.- Contraindicated: There is no prescription for ondansetron and no indication of nausea or vomiting from the client.
Inspect the bandage for drainage.- Indicated: Given the client’s recent surgery and the presence of swelling and bruising, it’s important to monitor for any signs of infection or complications.

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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

While caring for a client with a full thickness burn covering 40% of the body surface area (BSA), the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, which of the client’s laboratory values should the nurse note?

Correct Answer is D

Explanation

Exhibits Click to indicate which interventions the nurse should perform to care for this client. Each row must have one response indicated.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"}}

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