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A client with acute respiratory distress syndrome (ARDS) is on a ventilator. The client's peak inspiratory pressures and spontaneous respiratory rate are increasing, and the PO2 is not improving. Using the SBAR (Situation-Background-Assessment-Recommendation) technique for communication, the nurse calls the physician with the recommendation for:
- A. Initiating I.V. sedation.
- B. Starting a high-protein diet.
- C. Providing pain medication.
- D. Increasing the ventilator rate.
Correct Answer: A
Rationale: Increasing peak pressures, respiratory rate, and poor PO2 suggest agitation or asynchrony; I.V. sedation improves ventilator synchrony. Diet and pain medication are irrelevant. Increasing ventilator rate may worsen lung injury.
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What is the nurse's best action for a client with a C6 spinal cord injury?
- A. Assess respiratory status.
- B. Check bladder function.
- C. Monitor skin integrity.
- D. Evaluate motor strength.
Correct Answer: A
Rationale: Assessing respiratory status is the priority due to potential diaphragmatic impairment in a C6 injury.
A client with rib fractures and a pneumothorax has a chest tube inserted that is connected to a water-seal chest tube drainage system. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. What is the significance of this fluctuation?
- A. An obstruction is present in the chest tube.
- B. The client is developing subcutaneous emphysema.
- C. The chest tube system is functioning properly.
- D. There is a leak in the chest tube system.
Correct Answer: C
Rationale: Fluctuation in the water-seal column with breathing indicates a patent chest tube system, reflecting pleural pressure changes. Obstruction, emphysema, or leaks would show different signs.
To provide oral hygiene for a client recovering from transsphenoidal hypophysectomy, the nurse should instruct the client to:
- A. Rinse the mouth with saline solution.
- B. Perform frequent toothbrushing.
- C. Clean the teeth with an electric toothbrush.
- D. Floss the teeth thoroughly.
Correct Answer: A
Rationale: Saline mouth rinses are gentle and safe post-transsphenoidal hypophysectomy, avoiding irritation to the surgical site.
The nurse is taking care of a client who had a laryngectomy yesterday. To assure client safety, the nurse should give 'hand-off reports' at which of the following times? Select all that apply.
- A. Change of shift.
- B. Change of nurses.
- C. When nurse goes to lunch.
- D. When unit clerk goes to a staff meeting.
- E. When new medication orders are written.
Correct Answer: A,B,C
Rationale: Hand-off reports are critical at change of shift, change of nurses, and when the nurse goes to lunch to ensure continuity of care and client safety.
The nurse is a member of a team that is planning a client-centered approach to care of clients with chronic obstructive pulmonary disease (COPD) using the Chronic Care Model (CCM). The team should focus on improving quality of care and delivery in which of the following areas? Select all that apply.
- A. The community.
- B. Clinical information systems.
- C. Delivery system design.
- D. Administrative leadership.
- E. Emphasis on the acute care setting.
Correct Answer: A,B,C
Rationale: The Chronic Care Model emphasizes community resources (A), clinical information systems (B), and delivery system design (C) for chronic disease management. Administrative leadership and acute care focus are less central.