Nokea
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.
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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.
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 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 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.
A client is on intravenous heparin to treat a pulmonary embolism. The client's most recent partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate?
- A. Decrease the heparin rate
- B. Increase the heparin rate
Correct Answer: B
Rationale: A PTT of 25 seconds is below the therapeutic range (typically 1.5"?2.5 times the control value of ~30 seconds), indicating insufficient anticoagulation. Increasing the heparin rate is necessary to achieve therapeutic levels and effectively treat the pulmonary embolism.