Nokea
A client is on mechanical ventilation and the client's spouse wonders why ranitidine (Zantac) is needed since the client only has lung problems. What response by the nurse is best?
- A. It will increase the motility of the gastrointestinal tract
- B. It will keep the gastrointestinal tract functioning normally
- C. It will prepare the gastrointestinal tract for enteral feedings
- D. It will prevent ulcers from the stress of mechanical ventilation
Correct Answer: D
Rationale: Ranitidine, a histamine blocker, is used prophylactically to prevent stress ulcers, which are common in mechanically ventilated clients due to physiological stress.
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A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication should the nurse anticipate the client will need as the priority?
- A. Alteplase (Activase)
- B. Enoxaparin (Lovenox)
- C. Unfractionated heparin
- D. Warfarin sodium (Coumadin)
Correct Answer: A
Rationale: Alteplase is a thrombolytic indicated for large pulmonary embolisms with hemodynamic instability to rapidly dissolve the clot and restore circulation.
A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg. What action by the nurse is best?
- A. Administer oxygen at 2 L/min via nasal cannula
- B. Obtain a STAT chest X-ray
- C. Prepare to administer thrombolytic therapy
- D. Monitor the client's blood pressure every 15 minutes
Correct Answer: C
Rationale: The client's symptoms of anxiety, shortness of breath, chest pain, and hypotension suggest a pulmonary embolism, which can significantly impair gas exchange. Thrombolytic therapy is indicated for a large pulmonary embolism causing hemodynamic instability, as it can dissolve the clot and restore oxygenation.
The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.)
- A. Adherence to proper hand hygiene
- B. Administering anti-ulcer medication
- C. Elevating the head of the bed
- D. Providing oral care per protocol
- E. Suctioning the client on a regular schedule
Correct Answer: A,B,C,D
Rationale: The ventilator bundle to prevent ventilator-associated pneumonia includes hand hygiene, anti-ulcer medications, elevating the head of the bed (30"?45 degrees), and frequent oral care. Suctioning is performed as needed, not on a fixed schedule.
A nurse is preparing to admit a client on mechanical ventilation from the emergency department. What action by the nurse takes priority?
- A. Assessing that the ventilator settings are correct
- B. Ensuring there is a bag-valve-mask in the room
- C. Obtaining personal protective equipment
- D. Planning to suction the client upon arrival to the room
Correct Answer: B
Rationale: A bag-valve-mask is critical for manual ventilation in case of ventilator failure, making it the priority to ensure client safety.
A client on the emergency department has several broken ribs. What care measure will best promote comfort?
- A. Allowing the client to choose the position in bed
- B. Humidifying the supplemental oxygen
- C. Using the proper amount of water
- D. Providing warmed blankets
Correct Answer: A
Rationale: Allowing the client to choose a position of comfort (often upright) improves both comfort and oxygenation in clients with respiratory issues like broken ribs.