Q#21 A nurse caring for a client with acute respiratory failure on...

Question Answered step-by-step Q#21 A nurse caring for a client with acute respiratory failure on… Q#21A nurse caring for a client with acute respiratory failure on mechanical ventilation. To prevent complications, which assessment would be most important for the nurse to include in the plan of care?o A 0- 10 pain assessmento Psychosocial nursing assessmento A complete skin assessment o The client’s ability to communicateQ#22The nurse is assessing a client with chronic obstructive pulmonary disease whose pulse oximetry reading is 85% on room air. Which instruction would the nurse give to the licensed practical nurse (LPN)?o ‘Apply oxygen via rebreather mask at 2L/min.’o ‘Prepare client for intubation and mechanical ventilation’o ‘Administer oxygen and quickly increase rate to 10 L/min.’o ‘Apply oxygen and slowly increase to a flow rate of 4L/min.’Q#23A nurse is analysing a client’s lab values. What lab can influence the client’s oxygenation status?o D-dimer assayo Glomerular filtration rateo Percentage of neutrophilso Hemoglobin levelQ#24The primary healthcare provider ordered an IV infusion of magnesium sulfate at 7 mL/hr. The medication available is 10, 000 mg of magnesium sulfate in 500 mL NS. How many mg is the client receiving per minute? (If needed, round to the nearest tenth.) Write the number only. Q#25The primary healthcare provider ordered an IV infusion of nitroprusside at 0.3 mcg/kg/min. The client weighs 68 lb. How many mg is the client receiving per minute? Write the number only (Do not round) Q#26The healthcare team I conducting a spontaneous breathing trial using continuous positive airway pressure (CPAM). The nurse notes nasal flaring and retractions. The client heart rate is 130 beats/min, blood pressure 165/90 mm Hg, respiratory rate 7 breath/min. Which is t5he priority nursing action?o Place the client in the prone positiono Liberate the client from the ventilatoro Obtain an order for arterial blood gaseso Assess airway patency and manually ventilate the client.Q#27Four hours after mechanical ventilation is initiated, a client’s arterial blood gas (ABG) results include a pH of 7.51, PaO2 of 82 mm Hg, PaCO2 of 26 mm Hg, and HCO3- of 23 mEq/L (23mmol/L). What change should the nurse anticipate to the ventilator setting?o Increase the FiO2o Increase the tidal volume o Increase the respiratory rateo Decrease the respiratory rateQ#28The nurse reviews the complete blood cell (CBC) count results for a client who is scheduled for surgery. The results are white blood cell (WBC) count 10.2 * 103/uL, haemoglobin 15 g/dL; haematocrit 45%; platelets 150 * 103/uL. Which action should the nurse take?o Notify the surgeon and anesthesiologist immediatelyo Ask the client about any symptoms of a recent infectiono Continue to prepare the client for the surgical procedureo Discuss the possibility of blood transfusion with the clientQ# 29The nurse obtains a blood pressure of 176/82 mm Hg for a client. What is the client’s mean arterial pressure (MAP)? (Round to the nearest whole number) Write the number only. Q# 30While in the holding area, a client reveals to the nurse that his father had a high fever after surgery. What action taken by the nurse is a priority?o Place a medical alert sticker on the front of the client’s chart.o Alert the anesthesia care provider of the family member’s reaction to surgery.o Give 650 mg of acetaminophen per rectum as a preventive measureo Reassure the client that his temperature will be monitored closely after surgery.Q#31 When caring for a client who has received a general anesthetic, the circulating nurse notes red, raised wheals on the client’s arms. Which is the best nursing action?o Apply lotion to the affected areaso Cover the arms with sterile drapeso Recheck the client’s arms during surgeryo Notify the anesthesia care practitioner (ACP)Q#32Which actions will the nurse include in the surgical time-out procedure before surgery?o Have the client state name and date of birtho Assess the client’s urine outputo Check for patency of IV lineso Have the surgeon identify the clientQ#33A postoperative client has not voided for 8 hours after return to the clinical unit. Which action should the nurse take first?o Perform a bladder scano Insert a straight cathetero Encourage increased oral fluid intakeo Assist the client to ambulate to the bathroomQ#34The nurse is caring for a mechanically ventilated client and responds to a high peak respiratory pressure alarm. Which are possible causes for the alarm? [Select all that apply]o Agonal breathingo Secretions in the airwayo Kinks in the ventilator tubingo Coughing or attempting to talko Disconnection from the ventilator Q#35The nurse is attempting to wean a client from the ventilator. The client is not tolerating the weaning process. Which assessment findings are potential causes of difficulty weaning? [Select all that apply]o Hemoglobin 8g/dLo Blood pressure 100/98 mmHgo Decreasing level of consciousnesso Cardiac output of 4 liters per minuteo Bilateral infiltrates noted on chest x-rayQ#36The nurses is caring for an unresponsive terminally ill patient who has 20-second periods of apnea followed by periods of deep and rapid breathing. Which action by the nurse would be appropriate?o Suction the patient’s moutho Administer oxygen via face masko Document Cheyne-Stokes respirationso Place the patient in high Fowler’s positionQ#37The nurse is caring for a patient with lung cancer in a home hospice program. Which action by the nurse is appropriate?o Discuss cancer risk factors and appropriate lifestyle modificationso Teach the patient about the purpose of chemotherapy and radiationo Encourage the patient to discuss past life events and their meaningso Accomplish a thorough head-to-toe assessment several times a weekQ#38A hospice nurse who has become close to a terminally ill patient is present in the home when the patient dies and feels saddened and tearful as the family members begin to cry. Which action should the nurse take at this time?o Contact a grief counsellor as soon as possibleo Cry along with the patient’s family memberso Leave the home quickly to allow the family to grieve privatelyo Consider leaving the hospice work because patient losses are commonQ#39The nurse admits a terminally ill patient to the hospital. What is the first action that the nurse should complete when planning the patient’s care?o Determine the patient’s wishes regarding end-of-life careo Emphasize the importance of addressing any family issueso Discuss the normal grief process with the patient and familyo Encourage the patient to talk about the fears or unresolved issuesQ#40A patient who is lethargic and exhibits deep, rapid respirations has the following arterial blood gas (ABG) results pH 7.32, PaO2 88 mmHg, PaCO2 37mmHg, and HCO3 16 mEq/L. How should the nurse interpret these results?o Metabolic acidosiso Metabolic alkalosiso Respiratory acidosiso Respiratory alkalosis Health Science Science Nursing COMPLEX CR NR 341 Share QuestionEmailCopy link Comments (0)