The client is a 55-year-old male who was admitted to the hospital 1 week ago for sepsis. The client has been intubated since admission.
Current ventilator settings are synchronized intermittent mandatory ventilation (SIMV) respiratory rate 15 breaths/minute, tidal volume (TV) 500 mL, fraction of inspired oxygen (FiO) 40%. Based on the client’s status at 1400, the nurse should plan to do which of the following?
Continue weaning the ventilator as ordered.
Decrease the tidal volume.
Switch the ventilator to pressure control.
Increase the fractional concentration of inspired oxygen.
Increase the respiratory rate.
Change the ventilator settings to continuous positive airway pressure (CPAP).
Alert the provider of the blood gas values.
Correct Answer : A
Choice A rationale
For a client who has been intubated and is on a ventilator due to sepsis, the most appropriate action based on the client’s status would be to continue weaning the ventilator as ordered.
Weaning is the process of gradually reducing ventilator support, and it is typically initiated once the underlying cause of respiratory failure has been addressed. In this case, if the client’s condition has stabilized and there are no contraindications, continuing the weaning process as ordered would be the most appropriate action.
Choice B rationale
Decreasing the tidal volume is not necessarily the most appropriate action based on the client’s status. Tidal volume is the amount of air that is inhaled or exhaled during normal breathing.
While adjustments to tidal volume may be necessary in some cases, such as if the client is experiencing discomfort or if there are concerns about lung injury, there is no information in the scenario to suggest that a decrease in tidal volume is required at this time.
Choice C rationale
Switching the ventilator to pressure control is not necessarily the most appropriate action based on the client’s status. Pressure control ventilation is a mode of ventilation that can be used in certain situations, such as when there is a need to limit airway pressures. However, there is no information in the scenario to suggest that this change is required at this time.
Choice D rationale
Increasing the fractional concentration of inspired oxygen is not necessarily the most appropriate action based on the client’s status. The fraction of inspired oxygen (FiO2) is the concentration of oxygen in the gas mixture that the client is breathing. While adjustments to FiO2 may be necessary in some cases, such as if the client’s oxygen levels are low, there is no information in the scenario to suggest that an increase in FiO2 is required at this time.
Choice E rationale
Increasing the respiratory rate is not necessarily the most appropriate action based on the client’s status. The respiratory rate is the number of breaths that the client takes per minute, and it can be adjusted on the ventilator to meet the client’s needs. However, there is no information in the scenario to suggest that an increase in the respiratory rate is required at this time.
Choice F rationale
Changing the ventilator settings to continuous positive airway pressure (CPAP) is not necessarily the most appropriate action based on the client’s status. CPAP is a mode of ventilation that can be used in certain situations, such as during the weaning process. However, there is no information in the scenario to suggest that this change is required at this time.
Choice G rationale
Alerting the provider of the blood gas values is not necessarily the most appropriate action based on the client’s status. While it is important to communicate significant changes or concerns to the provider, there is no information in the scenario to suggest that the blood gas values are abnormal or require immediate attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
While a case management evaluation of the client’s home environment could potentially identify areas for improvement, it may not directly address the caregiver’s immediate need for relief from their caregiving responsibilities. The caregiver is experiencing sleepless nights and frequent bouts of crying, which could be signs of caregiver burnout or depression. Therefore, immediate respite care may be more beneficial.
Choice B rationale
Employing a private duty nurse for respite could provide temporary relief for the caregiver. However, this option might not be feasible due to potential financial constraints. Additionally, it may not provide the caregiver with the emotional support they may need.
Choice C rationale
Proposing that extended family could relocate to the area to provide support is a potential long-term solution. However, it may not be feasible or practical for extended family members to relocate. This option also does not address the caregiver’s immediate need for relief and support.
Choice D rationale
Advising the caregiver to contact social services to locate a respite care facility for the client could provide the caregiver with the immediate relief they need. Respite care facilities offer temporary relief for caregivers by providing short-term care for the individual they are caring for. This would allow the caregiver to rest and take care of their own needs, which could help alleviate their symptoms of sleepless nights and frequent bouts of crying.
Correct Answer is []
Explanation
Correct Actions:
Administer calcium as prescribed - Administering calcium (usually IV calcium gluconate) corrects the calcium deficiency, stabilizes nerve and muscle function, and helps stop or prevent further seizures.
Monitor respiratory status - Monitoring respiratory rate, effort, and oxygen saturation ensures early detection of hypoventilation, apnea, or oxygen desaturation.Maintaining airway and oxygenation is critical for safety and preventing hypoxia.
Correct Condition:
Hypocalcemia, or low calcium levels in the blood, can cause seizures in infants. Phenytoin, the medication given to the baby in the ambulance, is used to control seizures. Therefore, hypocalcemia could be the condition the infant is experiencing.
Correct Parameters to monitor:
Monitoring the respiratory rate is an important part of assessing any patient’s condition, especially an infant who has had a seizure.
Monitor serum calcium levels - Maintaining calcium within the normal neonatal range prevents recurrent seizures, cardiac arrhythmias, or neuromuscular irritability.
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