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Exhibits

To start the client on oxygen as ordered, what item(s) should the nurse collect from the supply room? Select all that apply.

Humidifier bottle

Lamb's wool

Flowmeter

Tape

Suction cannister

Nasal cannula

Sterile water

Answer and Explanation

Correct Answer : A,C,F,G

A. Humidifier bottle

Rationale: A humidifier bottle is often used with oxygen therapy to add moisture to the oxygen, preventing dryness of the nasal passages and throat. It is important for patient comfort, especially when oxygen is administered at higher flow rates for prolonged periods.

B. Lamb's wool

Rationale: Lamb's wool is not needed for starting oxygen therapy. It is typically used to provide padding and comfort in other situations, such as preventing pressure sores, but it has no role in the administration of oxygen.

C. Flowmeter

Rationale: A flowmeter is necessary to regulate the flow rate of oxygen. It ensures that the client receives the prescribed amount of oxygen (3 L/minute in this case), making it an essential component for administering oxygen therapy.

D. Tape

Rationale: Tape is not required for administering oxygen via a nasal cannula. It might be used to secure tubing in other contexts, but it is not specifically needed for starting oxygen therapy. The nasal cannula usually stays in place without the need for tape.

E. Suction cannister

Rationale: A suction canister is used in suctioning procedures to collect secretions and is not needed for starting oxygen therapy. It is relevant for managing airway secretions but unrelated to the administration of oxygen.

F. Nasal cannula

Rationale: A nasal cannula is the device through which oxygen is delivered to the client. It is specifically mentioned in the order and is essential for administering the oxygen.

G. Sterile water

Rationale: Sterile water is used to fill the humidifier bottle to provide humidified oxygen. This helps to prevent the drying effects of oxygen therapy on the mucous membranes, enhancing patient comfort.

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Correct Answer is ["A","F","G"]

Explanation

A. Increase the fractional concentration of Inspired oxygen: As the partial pressure of oxygen (PaO) has decreased to 64 mm Hg from 99 mm Hg, and the oxygen saturation may drop, it's necessary to increase the fraction of inspired oxygen (FiO2) to maintain adequate oxygenation.
B. Change the ventilator settings to continuous positive airway pressure (CPAP): CPAP is not typically used in patients who are intubated. CPAP is a non-invasive ventilation mode used for patients with respiratory distress who are breathing spontaneously. In this case, the patient is intubated and requires mechanical ventilation, so CPAP is not appropriate.
C. Increase the respiratory rate: While the respiratory rate has decreased from 15 to 13 breaths/minute, it's important to maintain a careful balance when adjusting ventilator settings. Increasing the respiratory rate may not be necessary at this point, especially if the patient is still oxygenating adequately. Moreover, the primary concern appears to be hypoxemia rather than hypoventilation.
D. Continue weaning the ventilator as ordered: While weaning the patient off the ventilator is a goal, it may not be appropriate at this time, especially with the worsening blood gas values
indicating respiratory insufficiency. Continuing the weaning process could potentially exacerbate respiratory failure.

E. Decrease the tidal volume: Decreasing the tidal volume could worsen ventilation-perfusion matching and exacerbate hypoxemia. This approach might be considered in certain cases of acute respiratory distress syndrome (ARDS) or in patients with severe lung injury, but it's not typically indicated in this scenario without further assessment.

F. Alert the provider of the blood gas values: The nurse should inform the provider about the changes in blood gas values, especially the decrease in PaO2 and the increase in PaCO2, which indicate worsening respiratory status and potential respiratory acidosis.

G. Switch the ventilator to pressure control: Given the deterioration in respiratory status with an increase in PaCO2 and decrease in PaO2, switching to pressure control ventilation may provide better control over the patient's ventilation and oxygenation, especially in cases of acute
respiratory failure.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"B"}

Explanation

A. anaphylaxis

The correct answer is A. Anaphylaxis is a severe, life-threatening allergic reaction that can occur in response to medication administration. The client's symptoms of dizziness, headache, burning feeling on extremities, and redness on face and extremities, along with the sudden onset of symptoms after starting vancomycin infusion, are indicative of a possible anaphylactic reaction.

B. arrhythmias

The correct answer is B. Arrhythmias refer to abnormal heart rhythms, which can be

triggered by various factors including medication reactions. Given the client's history of symptomatic bradycardia and the sudden onset of symptoms after starting vancomycin infusion, arrhythmias such as bradycardia or other rhythm disturbances are a concern.

C. Cardiac arrest

The correct answer is C. Cardiac arrest is the cessation of normal heart function, which can be precipitated by severe arrhythmias or anaphylaxis. The client's symptoms, along with the drop in blood pressure, indicate a potential risk of progressing to cardiac arrest if not promptly treated.

D. Necrosis

Necrosis, or tissue death, is not typically associated with the symptoms described in the scenario. While vancomycin infusion can potentially cause tissue irritation or damage at the
injection site, the symptoms described suggest a systemic reaction rather than localized tissue necrosis.

E. Renal failure

Renal failure is not directly indicated by the symptoms described in the scenario. While vancomycin can be nephrotoxic in some cases, the symptoms of dizziness, headache, and redness are more suggestive of an allergic or cardiovascular reaction.

F. Peripheral edema

Peripheral edema, or swelling in the extremities, is not indicated by the symptoms described in the scenario. The client's symptoms, such as dizziness, headache, and redness, are more
indicative of a systemic reaction rather than localized swelling.

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Exhibits To start the client on oxygen as ordered, what item(s) should the nurse collect from the supply room? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits Based on the client's status at 1400, the nurse should plan to do which of the following? Select all that apply.

Correct Answer is ["A","F","G"]

Explanation

Exhibits The nurse would determine what actions to implement in an emergent situation. Drag from Word Choices to complete the sentence. The client is at immediate risk for developing dropdown-1,dropdown-2 and dropdown-3

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"B"}

Explanation

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Exhibits

To start the client on oxygen as ordered, what item(s) should the nurse collect from the supply room? Select all that apply.