The client Is in the intensive care unit on a ventilator. Which intervention(s) should the nurse implement? (SELECT ALL THAT APPLY)

Assess the respiratory status hourly and as needed

Ensure that a manual resuscitation bag is at the bedside

Check the patient's pulse co once every shift

Adjust the ventilator settings based on the client’s level of consciousness

Collaborate frequently with the respiratory therapist

Answer and Explanation

Correct Answer : A,B,E

A) Assess the respiratory status hourly and as needed
It is essential for the nurse to frequently monitor and assess the respiratory status of a client on a ventilator, as changes can occur rapidly. Regular assessments allow the nurse to detect any early signs of respiratory distress, hypoxia, or ventilator malfunction. Hourly assessments are standard practice in the intensive care unit (ICU), and additional assessments may be necessary if there are concerns about the patient’s respiratory condition.

B) Ensure that a manual resuscitation bag is at the bedside
A manual resuscitation bag (Ambu bag) is a critical piece of emergency equipment that should always be available at the bedside of a patient on mechanical ventilation. In the event of ventilator failure, accidental extubation, or sudden respiratory distress, the nurse needs to be able to provide manual ventilation.
C) Check the patient's pulse oximetry once every shift
Although monitoring pulse oximetry is important in ICU patients on a ventilator, checking it only once per shift is insufficient. Continuous monitoring of oxygen saturation via pulse oximetry is a much more appropriate approach to ensure the patient is adequately oxygenated, especially when on a ventilator.

D) Adjust the ventilator settings based on the client’s level of consciousness
Adjusting the ventilator settings should be done by the healthcare provider or respiratory therapist, not the nurse, unless directed by the provider. While the patient's level of consciousness can influence their respiratory drive, the nurse does not have the authority or expertise to modify ventilator settings based on consciousness levels.

E) Collaborate frequently with the respiratory therapist
Collaboration with the respiratory therapist is essential for managing a patient on a ventilator. Respiratory therapists have specialized training in ventilator management and can assist with adjusting ventilator settings, monitoring the patient’s lung function, and troubleshooting ventilator malfunctions.

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Correct Answer is ["13.7"]

Explanation

Given:

Ordered dose of Furosemide: 1 mg/kg

Patient weight: 121 lbs

Concentration of Furosemide: 40 mg/10 mL (4 mg/mL)

Step 1: Convert patient weight from pounds to kilograms:

1 pound (lb) = 0.453592 kilograms (kg)

Patient weight in kg = 121 lbs x 0.453592 kg/lb = 54.877832 kg

Step 2: Calculate the total dose of Furosemide:

Total dose (mg) = Ordered dose (mg/kg) x Patient weight (kg)

Total dose (mg) = 1 mg/kg x 54.877832 kg

Total dose (mg) = 54.877832 mg

Step 3: Calculate the volume to be administered:

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

Volume (mL) = 54.877832 mg / 4 mg/mL

Volume (mL) = 13.719458 mL

Step 4: Round to the nearest tenth:

Volume (mL) ≈ 13.7 mL

A. Intestines B. Liver C. Spleen D. Stomach

Correct Answer is C

Explanation

A) Intestines:
While abdominal trauma can affect the intestines, Kehr's sign, Cullen's sign, and Gray Turner's sign are more commonly associated with damage to the spleen rather than the intestines. Kehr's sign, in particular, is a hallmark of splenic injury, with pain referred to the left shoulder due to diaphragmatic irritation from blood in the peritoneum.

B) Liver:
Liver injuries often present with right upper quadrant pain, jaundice, and elevated liver enzymes. While liver injuries can cause internal bleeding, Cullen's and Gray Turner's signs are more closely associated with retroperitoneal bleeding from the spleen rather than liver injuries. Kehr's sign, which is left-sided shoulder pain, would not typically indicate a liver injury.

C) Spleen:
The spleen is the most likely abdominal organ affected in this case due to the left-sided rib fractures. When the spleen is injured (often as a result of blunt trauma), it can cause intraperitoneal hemorrhage. This bleeding can irritate the diaphragm, leading to Kehr's sign, which presents as left shoulder pain. Additionally, Cullen's sign (periumbilical bruising) and Gray Turner's sign (flank bruising) are indicative of retroperitoneal bleeding, which can occur with splenic rupture or laceration.

D) Stomach:
While stomach injuries can occur with blunt abdominal trauma, they are less likely to cause the signs and symptoms seen in this patient (Kehr's, Cullen's, and Gray Turner's signs). Stomach trauma typically leads to pain and potential perforation, but it doesn't often cause the peritoneal bleeding patterns seen with splenic injuries.

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The client Is in the intensive care unit on a ventilator. Which intervention(s) should the nurse implement? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient is ordered 1 mg/kg of furosemide IV push. The patient weights 121 lbs. The medication is supplied 40 mg/10 mL. How many mL should the nurse administer? (round to the nearest tenth)

Correct Answer is ["13.7"]

Explanation

In providing care to a patient who sustained left sided 10th through 12th rib fractures, the nurse notes Kehr's Cullen's and Gray Turner's signs during assessment. Which abdominal organ is most likely to be affected by this trauma?

Correct Answer is C

Explanation

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