Reference Range: 1329545.
A client receiving mechanical ventilation has a pH of 7.26, PaCO2 of 68 mm Hg, and a PaO2 of 92 mm Hg. Which intervention should the nurse implement?

Decrease expiratory flow time.

Decrease expiratory pressure.

Increase rate of ventilation.

Increase ventilator tidal volume.

Answer and Explanation

The Correct Answer is B

Choice A rationale:

Decreasing expiratory flow time is not the appropriate intervention in this case. The client's pH and PaCO2 levels suggest respiratory acidosis, which indicates inadequate ventilation. Increasing expiratory flow time might exacerbate the acidosis by reducing ventilation.

Choice C rationale:

Increasing the rate of ventilation (respiratory rate) is a potential intervention to improve the client's acid-base balance. However, it should be done cautiously and under medical supervision to avoid respiratory alkalosis. It is not the first-line intervention in this scenario.

Choice D rationale:

Increasing the ventilator tidal volume may help improve ventilation, but it should also be done under medical guidance to prevent barotrauma. It is not the initial intervention to address the client's respiratory acidosis.

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Correct Answer is C

Explanation

Choice A rationale:

Nausea can be a significant factor contributing to decreased food intake, but it is not the most likely cause in this scenario. Xerostomia (dry mouth) and mucositis are mentioned as symptoms in the question stem. Nausea alone does not explain why the client is consuming less than their body requirements.

Choice B rationale:

Fatigue can also contribute to decreased food intake, but it is not the most likely cause in this case. While fatigue can be a side effect of cancer treatment and may lead to reduced appetite, the question specifically mentions xerostomia and mucositis as issues contributing to imbalanced nutritional intake.

Choice C rationale:

Pain when eating is the most likely cause of imbalanced nutritional intake in this scenario. The client's laryngeal cancer and the development of mucositis indicate that eating is likely painful for them. This discomfort can significantly deter the client from eating, leading to decreased nutritional intake.

Choice D rationale:

Altered taste sensation can affect food preferences, but it is not the most likely cause in this case. Pain when eating is a more direct and immediate barrier to food intake, especially in the context of mucositis and laryngeal cancer.

A. Prescribe medication for immediate relief. B. Educate the client about various relaxation techniques. C. Assist the client in challenging irrational thoughts. D. Develop measurable and realistic outcomes.

Correct Answer is D

Explanation

Choice A rationale:

Prescribing medication for immediate relief is not the primary goal when establishing a therapeutic relationship with a client with anxiety disorder. While medication may be a part of the treatment plan, the primary focus should be on building trust and addressing the client's emotional needs.

Choice B rationale:

Educating the client about various relaxation techniques can be beneficial, but it is not the primary goal of establishing a therapeutic relationship. The primary goal is to create a trusting and supportive environment in which the client feels comfortable discussing their feelings and concerns.

Choice C rationale:

Assisting the client in challenging irrational thoughts is an important aspect of cognitive-behavioral therapy, but it is not the primary goal of establishing the therapeutic relationship. Building rapport and trust come first.

Choice D rationale:

Developing measurable and realistic outcomes is the primary goal when establishing a therapeutic relationship. These outcomes provide a framework for assessing progress and ensuring that the therapeutic interventions are effective in addressing the client's anxiety disorder.

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Reference Range: 1329545.A client receiving mechanical ventilation has a pH of 7.26, PaCO2 of 68 mm Hg, and a PaO2 of 92 mm Hg. Which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client who is receiving radiation treatment for laryngeal cancer has developed xerostomia and mucositis.The nurse determines the client has an imbalanced nutritional intake and is consuming less than body requirements.Which factor is the most likely cause for this problem?

Correct Answer is C

Explanation

A nurse is establishing a therapeutic relationship with a client with anxiety disorder.What is the primary goal of this intervention?

Correct Answer is D

Explanation

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Reference Range: 1329545.
A client receiving mechanical ventilation has a pH of 7.26, PaCO2 of 68 mm Hg, and a PaO2 of 92 mm Hg. Which intervention should the nurse implement?