Nokea
A 242-pound client is being mechanically ventilated. To prevent lung injury, what setting should the nurse anticipate for tidal volume? (Record your answer using a whole number.) mL
- A. 600 mL
- B. 660 mL
- C. 700 mL
- D. 750 mL
Correct Answer: B
Rationale: A tidal volume of 6 mL/kg is used to prevent lung injury. For a 242-pound (110 kg) client, 110 kg ? 6 mL/kg = 660 mL.
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A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate?
- A. Assess the cause of the agitation
- B. Reassure the client that he or she is safe
- C. Restrain the client's hands
- D. Sedate the client immediately
Correct Answer: A
Rationale: Determining the cause of agitation (e.g., pain, hypoxia, or anxiety) is the first step to address the underlying issue. Restraints or sedation may be needed but are not the initial action.
A client has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority?
- A. Apply oxygen at 100%
- B. Assess the respiratory rate
- C. Ensure a patent airway
- D. Start two large-bore IV lines
Correct Answer: C
Rationale: For chest trauma, the priority follows the ABCs (airway, breathing, circulation). Ensuring a patent airway is the first step to stabilize the client.
A client is being discharged soon on warfarin (Coumadin). What menu selection for dinner indicates the client needs more education regarding this medication?
- A. Hamburger and French fries
- B. Large chef's salad and muffin
- C. No selection, spouse brings pizza
- D. Tuna salad sandwich and chips
Correct Answer: B
Rationale: Warfarin inhibits vitamin K-dependent clotting factors. A large chef's salad with leafy greens high in vitamin K can interfere with warfarin's effectiveness, indicating a need for further education.
An intubated client's oxygen saturation has dropped to 88%. What action by the nurse takes priority?
- A. Determine if the tube is kinked
- B. Ensure all connections are patent
- C. Listen to the client's lung sounds
- D. Suction the endotracheal tube
Correct Answer: C
Rationale: For an intubated client with hypoxia, the nurse should first assess for DOPE (displaced tube, obstruction, pneumothorax, equipment problems). Listening to lung sounds to confirm tube placement is the priority, as a displaced tube is the most common cause of hypoxia.
A nurse is teaching a client about warfarin (Coumadin). What assessment finding by the nurse indicates a possible barrier to self-management?
- A. Poor visual acuity
- B. Strict vegetarian
- C. Refusal to stop smoking
- D. Wants weight loss surgery
Correct Answer: B
Rationale: A strict vegetarian diet high in vitamin K-rich foods can interfere with warfarin's anticoagulation effect, posing a barrier to consistent self-management.