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.

Answer and Explanation

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.

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Correct Answer is A

Explanation

Demonstrate how to administer medication via a feeding tube.The picture shows that the newly hired PN is about to make a serious error by adding the medication directly to the feeding bag, which can cause clogging, contamination, or inaccurate dosing of the medication. The PN should demonstrate how to administer medication via a feeding tube correctly, which involves stopping the feeding, ﬂushing the tube with water, instilling the medication, ﬂushing again, and resuming the feeding.

The other options are not correct because:

Confirming that the medication is only administered once daily is not relevant or helpful, as it does not address the error or teach the correct technique of administering medication via a feeding tube.Determining if the medication is compatible with the solution is not necessary or appropriate, as the medication should not be mixed with the solution in the first place, but given separately through the feeding tube.
Oﬀering to assist in calculating the rate of ﬂow for the mixture is not relevant or helpful, as there should be no mixture of medication and solution in the feeding bag, but separate administration of each through the feeding tube.

A. Affirm that the client should rise slowly from the chair. B. Tell the UAP to assist the client in moving more quickly. C. Demonstrate how to help the client move more efficiently. D. Offer a PRN analgesic to reduce painful movement.

Correct Answer is A

Explanation

A) Correct- Clients with Parkinson's disease often experience bradykinesia and impaired mobility. Rising slowly from a seated position is important to prevent falls and maintain stability. Affirming the correct movement strategy promotes the client's safety.
B) Incorrect- Telling the UAP to make the client move more quickly could be unsafe and not appropriate for a client with Parkinson's disease. Rapid movements might lead to balance issues or falls.
C) Incorrect- While demonstrating proper technique might be helpful, it's not the most immediate action the nurse should take. The client's safety and well-being are the priority.
D) Incorrect- Painful movement is not the primary issue here. The client's movement is slow due to Parkinson's disease, and this is expected.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The practical nurse (PN) is observing a newly hired PN who is preparing to administer a liquid medication via a client's feeding tube system as seen in the picture. What action should the PN take?

Correct Answer is A

Explanation

The nurse enters the room of a client with Parkinson's disease who is taking carbidopa-levodopa. The client is rising slowly from the chair while the unlicensed assistive personnel (UAP) stands next to the chair. Which action should the nurse take?

Correct Answer is A

Explanation

A 4-month-old infant is brought to the clinic by a parent with symptoms of a runny nose, a slight fever, and cough for the last two days Which finding should alert the nurse that the child is in acute respiratory distress?

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The practical nurse (PN) prepares to remove a client's saline lock. Which supplies should the PN gather? (Select all that apply.)

When conducting diet teaching for a client who is on a postoperative full-liquid diet, which food(s) should the nurse encourage the client to eat? (Select all that apply.)

Which actions should the practical nurse (PN) include when assessing a client for signs and symptoms of ﬂuid volume excess? (Select all that apply.)

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 adolescent who was diagnosed with type 1 diabetes mellitus at the age of 9, is admitted to the hospital in diabetic ketoacidosis. Which occurrence is the most likely cause of the ketoacidosis?

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.