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","C","D"]
Explanation
Client's pain rating on a scale of 1 to 10: This information helps assess the client's current pain level and determine the need for pain medication.
Time of the last administration of pain medication: This is important to avoid overdosing or administering pain medication too frequently. It helps ensure that pain medication is given at the appropriate time intervals.
Effectiveness of the last pain medication administered: Understanding whether the previous dose provided relief or not helps guide the choice of the next medication or dosage.
The other options are not directly related to the immediate decision of administering pain medication:
Height and weight of the client prior to admission may be part of the client's medical history but are not typically required information just before administering pain medication.
A history of pain medication use during the past year is important information but may be already documented in the client's medical records and not necessary to obtain immediately before administration.
Correct Answer is ["A","B","D","E"]
Explanation
A) Correct - Demonstrating the technique used to monitor blood glucose levels is crucial.
Incorrect technique can lead to inaccurate readings, impacting insulin dosing decisions and blood sugar control.
B) Correct - Some asthma medications, like corticosteroids, can elevate blood glucose levels.
Evaluating the client's asthma medications is essential as they can contribute to fluctuations in blood sugar levels.
C) Incorrect- Asking the client if they want a different manufacturer's glucose monitoring device is not helpful, because it does not address the underlying causes of the poor glycemic control. The client may also perceive this as a lack of confidence in their ability to manage their diabetes or as a criticism of their choice of device. The nurse should focus on educating the client on how to use their current device correctly and consistently, rather than suggesting a change that may not be necessary or feasible.
D) Correct - Understanding the client's daily routine helps identify factors influencing blood glucose control, such as meal timing, activity level, and stress. This information aids in creating a personalized diabetes management plan.
E) Correct - Ensuring the client uses a new insulin needle for each administration is important for preventing infection and complications. Reusing needles can affect injection site health and insulin absorption.
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