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Exhibits

Which actions can the nurse do to assist the client in improving their ventilation and oxygenation? Select all that apply.

Positioning the client with the head of the bed elevated

Avoid treating fever with antipyretics

Encourage the client to take breaks from the oxygen mask every few hours

Providing suctioning so the client does not have to cough

Assist the client in ambulating safely

Asking the client to do quick, shallow breaths

Teaching the client to cough at least once an hour

Answer and Explanation

Correct Answer : A,E,G

A. Positioning the client with the head of the bed elevated helps improve lung expansion and facilitates better ventilation and oxygenation, reducing the work of breathing.
B. Avoid treating fever with antipyretics is not appropriate, as managing fever can help reduce metabolic demand and improve overall comfort, which aids in ventilation.
C. Encouraging the client to take breaks from the oxygen mask is not advisable, as consistent oxygen delivery is critical for maintaining adequate oxygen saturation, especially in cases of pneumonia.
D. Providing suctioning so the client does not have to cough may not be necessary; coughing is a natural mechanism to clear secretions and improve airway patency.
E. Assisting the client in ambulating safely promotes lung expansion, enhances circulation, and aids in the mobilization of secretions, contributing positively to ventilation and oxygenation.
F. Asking the client to do quick, shallow breaths is counterproductive, as it can lead to inadequate ventilation and decreased oxygenation; deep breathing is preferred.
G. Teaching the client to cough at least once an hour is essential for clearing secretions and improving lung function, thereby enhancing ventilation and oxygenation.

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Correct Answer is ["100"]

Explanation

Infusion rate (mL/hr) = Volume (mL) / Time (hr)

Volume = Desired dose (mg) / Concentration (mg/mL)

Volume = 500 mg / 500 mg/mL = 100 mL

Infusion rate = 100 mL / 1 hr = 100 mL/hr

A. Determine the client's last dose of corticosteroids. B. Determine neurological baseline prior to the fall. C. Administer a PRN IV antiemetic as prescribed. D. Complete head-to-toe neurological assessment.

Correct Answer is D

Explanation

A. Determine the client's last dose of corticosteroids: This may be helpful later in understanding the client's MS management, but it is not the immediate priority in an acute neurological situation.
B. Determine neurological baseline prior to the fall: While important for comparison, establishing the client’s current status through assessment takes priority.
C. Administer a PRN IV antiemetic as prescribed: Vomiting may be a sign of increased intracranial pressure (ICP); treating the symptom without assessing for underlying neurological compromise could delay recognition of a critical condition.
D. Complete head-to-toe neurological assessment: This is the priority. The client’s confusion and projectile vomiting may indicate a traumatic brain injury with increased ICP. Immediate neurological assessment is necessary to identify life-threatening changes and guide urgent interventions.

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Exhibits Which actions can the nurse do to assist the client in improving their ventilation and oxygenation? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client receives a prescription for vancomycin 500 mg IV every 8 hours. The medication is provided in, "500 mg per 100 mL of dextrose 5% in water." To administer the medication over an hour, the nurse should set the infusion pump to deliver how many mL/hr? (Enter numerical value only.)

Correct Answer is ["100"]

Explanation

A client with multiple sclerosis (MS) fell while walking to the bathroom. Upon transfer to the intensive care unit, the client is confused and has had projectile vomiting twice. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

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Exhibits

Which actions can the nurse do to assist the client in improving their ventilation and oxygenation? Select all that apply.