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 ["0.8"]
Explanation
Step 1: Convert the client’s weight from pounds to kg. 1 kg is approximately 2.2 lbs. So, 176 lbs
÷ 2.2 = 80 kg (rounded to the nearest whole number).
Step 2: Calculate the total mg of enoxaparin sodium needed per day. The prescription is for 1.5 mg/kg/day. So, 80 kg × 1.5 mg/kg/day = 120 mg/day.
Step 3: Calculate the mL of enoxaparin sodium needed. The medication is available in a 120 mg/0.8 mL prefilled syringe. So, 120 mg ÷ 120 mg/0.8 mL = 0.8 mL. The nurse should administer 0.8 mL.
Correct Answer is D
Explanation
Choice A rationale
Offering the client oral fluids is important for hydration, but it is not directly related to the care of an indwelling urinary catheter. The UAP can offer fluids to the client, but this action is not specifically tied to the turning of the client or the care of the urinary catheter.
Choice B rationale
Feeding the client a snack is a task that the UAP may perform, but it is not directly related to the care of an indwelling urinary catheter. The UAP can provide a snack to the client, but this action is not specifically tied to the turning of the client or the care of the urinary catheter.
Choice C rationale
Assessing breath sounds is within the scope of practice for a nurse, not a UAP. While it’s important to monitor a client’s respiratory status, this action is not directly related to the care of an indwelling urinary catheter.
Choice D rationale
Emptying the urinary drainage bag is an appropriate action for the UAP to take each time the client is turned. This action helps to prevent infection, maintain accurate intake and output records, and ensure the comfort and dignity of the client.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.