The nurse is managing 4 clients in the intensive care unit who are mechanically ventilated.
After performing a quick visual assessment, the nurse should prioritize care for the client who is exhibiting which finding.
An audible voice when client is trying to communicate.
Diminished breath sounds In the right posterior base.
Restrained and restless with a low volume alarm sounding.
High pressure alarm sounds when client is coughing.
The Correct Answer is C
A) Incorrect- an audible voice when client is trying to communicate, indicates that the client has some air passing through the vocal cords, which may be due to a partially deflated cuff or a speaking valve. This is not a life-threatening situation, but the nurse should ensure that the cuff pressure is adequate and that the client is not experiencing any discomfort or aspiration risk.
B) Incorrect- This may indicate atelectasis, pneumonia, or pleural effusion in that lung area. The nurse should auscultate the client's lungs more thoroughly, monitor the client's oxygenation and ventilation parameters, and report the findings to the provider.
C) Correct- This finding suggests that the client may have a ventilator disconnect, a leak in the circuit, or a cuff leak, which can compromise the client's oxygenation and ventilation. The nurse should immediately check the ventilator connections and tubing, and assess the client's vital signs and oxygen saturation.
D) Incorrect- high-pressure alarm sounds when the client is coughing, which is a common occurrence in mechanically ventilated clients who have increased airway resistance due to secretions, bronchospasm, or coughing. The nurse should suction the client as needed, administer bronchodilators if prescribed, and ensure that the ventilator settings are appropriate for the client's condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
A) Correct- Continuous monitoring of oxygen saturation ensures the client's oxygen levels remain within an acceptable range.
B) Incorrect - Discussing aggressive respiratory treatment options is not warranted based on the provided information. The current treatment plan includes appropriate interventions.
C) Incorrect - Obtaining a sputum culture is important for identifying infections, but it's not an immediate action in the context of the client's current symptoms.
D) Correct- Promoting comfort can help reduce anxiety and potentially improve breathing.
E) Correct- Educating the client about potential triggers supports better self-management.
F) Incorrect - Considering positive pressure ventilation is not indicated at this stage. The client's symptoms are being managed with other interventions.
G) Incorrect - Weaning supplemental oxygen is not mentioned in the patient data or nurses' notes as something that's currently necessary.
H) Incorrect - Preparing for deep tracheal suctioning is not warranted based on the patient data and the current treatment plan.
Correct Answer is C
Explanation
The client may be experiencing postoperative delirium, which is a transient state of confusion, disorientation, agitation, or hallucinations that can occur after surgery, especially in elderly clients. The PN should raise the side rails and notify the family to come and stay with the client, as this can provide safety, comfort, and reassurance for the client.
The other options are not correct because:
A. Administering a prescribed narcotic antagonist may not be appropriate or necessary, as the client's agitation may not be caused by analgesic accumulation, but by other factors such as hypoxia, infection, electrolyte imbalance, or sensory deprivation.
B. Notifying the healthcare provider and requesting a prescription for restraints may not be the best intervention, as restraints can increase the client's agitation, anxiety, or injury. Restraints should be used only as a last resort when other measures have failed or when there is an imminent risk of harm.
D. Instructing a UAP to keep the upper side rails up and check on the client every 15 minutes may not be sufficient or effective, as the client may still try to get out of bed or become more agitated by being left alone. The PN should involve the family or stay with the client until he or she is calm and oriented.
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