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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

Responding to the code while performing tracheostomy care could potentially put the current patient at risk. The nurse has a responsibility to ensure the safety of the patient they are currently caring for.

Choice B rationale

Closing the room door does not address the immediate needs of either patient and does not contribute to the safety or care of the patients.

Choice C rationale

Calling for an assistant is the most appropriate action. This allows the nurse to ensure the safety of the current patient while also allowing for a response to the code blue. The assistant can continue care for the current patient, or the nurse can delegate the assistant to respond to the code while the nurse continues care for the current patient.

Choice D rationale

Finishing the procedure could delay response to the code blue, potentially putting the other patient at risk.

A. Apply ice, then a warm compress to the IV site. B. Check the medical record for the date of IV insertion. C. Redress the IV site while checking for redness. D. Discontinue the current IV site and insert a new one.

Correct Answer is D

Explanation

Choice A rationale

Applying ice, then a warm compress to the IV site may help with pain or inflammation, but it does not address the potential problem with the IV site itself. If the client is experiencing pain and refuses a flush to assess the site, it could indicate that the IV site is compromised.

Choice B rationale

Checking the medical record for the date of IV insertion could provide useful information about how long the IV has been in place, but it does not directly address the client’s current complaint of pain at the IV site.

Choice C rationale

Redressing the IV site while checking for redness could help identify signs of infection or inflammation, but it does not address the client’s complaint of pain or their refusal to have the site flushed.

Choice D rationale

Discontinuing the current IV site and inserting a new one is the most appropriate action in this situation. If the client is experiencing pain at the IV site and refuses a flush to assess the site, it suggests that the current IV site may be compromised. Inserting a new IV ensures that the client can continue to receive their scheduled IV medication safely.

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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

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?

Correct Answer is C

Explanation

While preparing to administer a scheduled IV medication, a client complains of pain at the IV site and refuses a flush to assess the site.What should the nurse do next?

Correct Answer is D

Explanation

The nurse is reviewing the nurse’s notes and flow chart to identify trends.Which notations require immediate follow-up?

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

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A patient has developed signs and symptoms of septic shock following a urinary tract infection one week ago.The healthcare provider has prescribed a sepsis protocol to be initiated.Which intervention should the nurse prioritize in the plan of care?

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