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 ["B","D"]
Explanation
A) Incorrect - Providing a regular diet tray is important for the client's nutritional needs, but it is not as urgent as assessing vital signs or administering Albuterol in response to the client's acute symptoms.
B) Correct- This action is a priority after any assessment or intervention. Vital signs provide important information about the client's overall condition, including heart rate, blood pressure, respiratory rate, and oxygen saturation.
C) Incorrect - Applying oxygen is important, but its priority depends on the client's vital signs and oxygen saturation, which should be assessed first.
D) Correct- Administering Albuterol as ordered is crucial for addressing the client's acute breathing difficulty. Albuterol is a bronchodilator that helps alleviate asthma symptoms, and timely administration is essential.
E) Incorrect - Performing a pulmonary function test is valuable for assessing lung function, but it's not an immediate concern compared to addressing the client's breathing difficulty.
Correct Answer is C
Explanation
- An oil retention enema is used to soften the stool and lubricate the rectum, making it easier to pass the stool. It is usually oil-based and contains 90-120 ml of solution.
- The temperature of the enema solution affects the effectiveness and comfort of the procedure. If the solution is too hot or cold, it can cause pain, cramps, or damage to the rectal tissue³. If the solution is too warm, it can also stimulate peristalsis and cause the client to expel the enema before it has time to work.
- The ideal temperature for an enema solution is close to the client’s body temperature, which is around 98°F or 36°C. This temperature ensures that the solution is comfortable and does not cause adverse reactions.
Option A is incorrect because the client’s comfort level may not reflect the optimal temperature for the enema.
Option B is incorrect because the temperature of the enema does affect its effectiveness and safety.
Option D is incorrect because the temperature is too high and can cause harm to the client.
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